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Starr MC, Barreto E, Charlton J, Vega M, Brophy PD, Ray Bignall ON, Sutherland SM, Menon S, Devarajan P, Akcan Arikan A, Basu R, Goldstein S, Soranno DE. Advances in pediatric acute kidney injury pathobiology: a report from the 26th Acute Disease Quality Initiative (ADQI) conference. Pediatr Nephrol 2024; 39:941-953. [PMID: 37792076 PMCID: PMC10817846 DOI: 10.1007/s00467-023-06154-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 08/08/2023] [Accepted: 08/29/2023] [Indexed: 10/05/2023]
Abstract
BACKGROUND In the past decade, there have been substantial advances in our understanding of the pathobiology of pediatric acute kidney injury (AKI). In particular, animal models and studies focused on the relationship between kidney development, nephron number, and kidney health have identified a number of heterogeneous pathophysiologies underlying AKI. Despite this progress, gaps remain in our understanding of the pathobiology of pediatric AKI. METHODS During the 26th Acute Disease Quality Initiative (ADQI) Consensus conference, a multidisciplinary group of experts discussed the evidence and used a modified Delphi process to achieve consensus on recommendations for opportunities to advance translational research in pediatric AKI. The current state of research understanding as well as gaps and opportunities for advancement in research was discussed, and recommendations were summarized. RESULTS Consensus was reached that to improve translational pediatric AKI advancements, diverse teams spanning pre-clinical to epidemiological scientists must work in concert together and that results must be shared with the community we serve with patient involvement. Public and private research support and meaningful partnerships with adult research efforts are required. Particular focus is warranted to investigate the pediatric nuances of AKI, including the effect of development as a biological variable on AKI incidence, severity, and outcomes. CONCLUSIONS Although AKI is common and associated with significant morbidity, the biologic basis of the disease spectrum throughout varying nephron developmental stages remains poorly understood. An incomplete understanding of factors contributing to kidney health, the diverse pathobiologies underlying AKI in children, and the historically siloed approach to research limit advances in the field. The recommendations outlined herein identify gaps and outline a strategic approach to advance the field of pediatric AKI via multidisciplinary translational research.
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Affiliation(s)
- Michelle C Starr
- Department of Pediatrics, Division of Nephrology, Indiana University School of Medicine, Riley Hospital for Children, 1044 W. Walnut Street, Indianapolis, IN, 46202, USA
- Pediatric and Adolescent Comparative Effectiveness Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Erin Barreto
- Department of Pharmacy, Mayo Clinic, Rochester, MN, USA
| | - Jennifer Charlton
- Department of Pediatrics, Division of Nephrology, University of Virginia, Charlottesville, VA, USA
| | - Molly Vega
- Renal and Apheresis Services, Texas Children's Hospital, Houston, TX, USA
| | - Patrick D Brophy
- Department of Pediatrics, Golisano Children's Hospital, University of Rochester, Rochester, NY, USA
| | - O N Ray Bignall
- Department of Pediatrics, Division of Nephrology and Hypertension, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, OH, USA
| | - Scott M Sutherland
- Department of Pediatrics, Division of Nephrology, Stanford University School of Medicine, Stanford, CA, USA
| | - Shina Menon
- Division of Pediatric Nephrology, Seattle Children's Hospital and University of Washington, Seattle, WA, USA
| | - Prasad Devarajan
- Department of Pediatrics, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - Ayse Akcan Arikan
- Department of Pediatrics, Divisions of Critical Care and Nephrology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Rajit Basu
- Department of Pediatrics, Division of Critical Care, Northwestern University, Chicago, IL, USA
| | - Stuart Goldstein
- Department of Pediatrics, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - Danielle E Soranno
- Department of Pediatrics, Division of Nephrology, Indiana University School of Medicine, Riley Hospital for Children, 1044 W. Walnut Street, Indianapolis, IN, 46202, USA.
- Department of Bioengineering, Purdue University, West Lafayette, IN, USA.
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Wong Vega M, Starr MC, Brophy PD, Devarajan P, Soranno DE, Akcan-Arikan A, Basu R, Goldstein SL, Charlton JR, Barreto E. Advances in pediatric acute kidney injury pharmacology and nutrition: a report from the 26th Acute Disease Quality Initiative (ADQI) consensus conference. Pediatr Nephrol 2024; 39:981-992. [PMID: 37878137 PMCID: PMC10817838 DOI: 10.1007/s00467-023-06178-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 09/14/2023] [Accepted: 09/15/2023] [Indexed: 10/26/2023]
Abstract
BACKGROUND In the past decade, there have been substantial advances in our understanding of pediatric AKI. Despite this progress, large gaps remain in our understanding of pharmacology and nutritional therapy in pediatric AKI. METHODS During the 26th Acute Disease Quality Initiative (ADQI) Consensus Conference, a multidisciplinary group of experts reviewed the evidence and used a modified Delphi process to achieve consensus on recommendations for gaps and advances in care for pharmacologic and nutritional management of pediatric AKI. The current evidence as well as gaps and opportunities were discussed, and recommendations were summarized. RESULTS Two consensus statements were developed. (1) High-value, kidney-eliminated medications should be selected for a detailed characterization of their pharmacokinetics, pharmacodynamics, and pharmaco-"omics" in sick children across the developmental continuum. This will allow for the optimization of real-time modeling with the goal of improving patient care. Nephrotoxin stewardship will be identified as an organizational priority and supported with necessary resources and infrastructure. (2) Patient-centered outcomes (functional status, quality of life, and optimal growth and development) must drive targeted nutritional interventions to optimize short- and long-term nutrition. Measures of acute and chronic changes of anthropometrics, body composition, physical function, and metabolic control should be incorporated into nutritional assessments. CONCLUSIONS Neonates and children have unique metabolic and growth parameters compared to adult patients. Strategic investments in multidisciplinary translational research efforts are required to fill the knowledge gaps in nutritional requirements and pharmacological best practices for children with or at risk for AKI.
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Affiliation(s)
- Molly Wong Vega
- Renal and Apheresis Services, Texas Children's Hospital, Houston, TX, USA
| | - Michelle C Starr
- Department of Pediatrics, Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, USA
- Pediatric and Adolescent Comparative Effectiveness Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Patrick D Brophy
- Department of Pediatrics, Golisano Children's Hospital, University of Rochester, Rochester, NY, USA
| | - Prasad Devarajan
- Division of Nephrology and Hypertension, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - Danielle E Soranno
- Department of Pediatrics, Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, USA
- Department of Bioengineering, Purdue University, West Lafayette, IN, USA
| | - Ayse Akcan-Arikan
- Divisions of Critical Care and Nephrology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Rajit Basu
- Division of Critical Care, Department of Pediatrics, Northwestern University, Chicago, IL, USA
| | - Stuart L Goldstein
- Division of Nephrology and Hypertension, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - Jennifer R Charlton
- Division of Nephrology, Department of Pediatrics, University of Virginia, Box 800386, Charlottesville, VA, 22901, USA.
| | - Erin Barreto
- Department of Pharmacy, Mayo Clinic, Rochester, MN, USA
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Cabana MD, de Alarcon PA, Allen E, Bean XD, Brophy PD, Degnon L, First LR, Dennery PA, Salazar JC, Schleien C, St Geme JW, Parra-Roide L, Walker-Harding LR. Diversity in Pediatrics Department Leadership Positions. J Pediatr 2024; 266:113557. [PMID: 37321288 DOI: 10.1016/j.jpeds.2023.113557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 06/12/2023] [Indexed: 06/17/2023]
Affiliation(s)
- Michael D Cabana
- Albert Einstein College of Medicine, Bronx, NY; Children's Hospital at Montefiore, Bronx, NY.
| | | | - Erin Allen
- University of Washington School of Medicine, Seattle, WA
| | | | - Patrick D Brophy
- University of Rochester Medical Center, Rochester, NY; Golisano Children's Hospital, Rochester, NY
| | | | - Lewis R First
- Robert Larner, M.D., College of Medicine at The University of Vermont, Burlington, VT
| | - Phyllis A Dennery
- Warren Alpert School of Medicine of Brown University, Providence, RI; Hasbro Children's Hospital, Providence, RI
| | - Juan C Salazar
- University of Connecticut School of Medicine, Farmington, CT; Connecticut Children's Hospital, Hartford, CT
| | - Charles Schleien
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY; Cohen Children's Medical Center, Queens, NY
| | - Joseph W St Geme
- Children's Hospital of Philadelphia, Philadelphia, PA; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Lilia Parra-Roide
- Creighton University School of Medicine, Phoenix Regional Campus, Phoenix, AZ
| | - Leslie R Walker-Harding
- University of Washington School of Medicine, Seattle, WA; Seattle Children's Hospital, Seattle, WA
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Cabana MD, de Alarcon PA, Allen E, Bean XD, Brophy PD, Cordova de Ortega L, Degnon L, First LR, Dennery PA, Salazar JC, Schleien C, St Geme JW, Parra-Roide L, Walker-Harding LR. Pediatric Department Approaches to Promote Diversity, Equity, and Inclusion. J Pediatr 2024:113951. [PMID: 38331346 DOI: 10.1016/j.jpeds.2024.113951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 02/04/2024] [Indexed: 02/10/2024]
Affiliation(s)
- Michael D Cabana
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY; Department of Pediatrics, Children's Hospital at Montefiore, Bronx, NY.
| | - Pedro A de Alarcon
- Department of Pediatrics, University of Illinois College of Medicine, Peoria, IL
| | - Erin Allen
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
| | - Xylina D Bean
- Department of Pediatrics, Meharry Medical College, Nashville, TN
| | - Patrick D Brophy
- Department of Pediatrics, University of Rochester Medical Center, Rochester, NY; Department of Pediatrics, Golisano Children's Hospital, Rochester, NY
| | | | | | - Lewis R First
- Department of Pediatrics, Robert Larner, M.D. College of Medicine at The University of Vermont, Burlington, VT
| | - Phyllis A Dennery
- Department of Pediatrics, Warren Alpert School of Medicine of Brown University, Providence, RI; Department of Pediatrics, Hasbro Children's Hospital, Providence, RI
| | - Juan C Salazar
- Department of Pediatrics, University of Connecticut School of Medicine, Farmington, CT; Department of Pediatrics, Connecticut Children's Hospital, Hartford, CT
| | - Charles Schleien
- Department of Pediatrics, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY; Department of Pediatrics, Cohen Children's Medical Center, Queens, NY
| | - Joseph W St Geme
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Lilia Parra-Roide
- Department of Pediatrics, Creighton University School of Medicine, Phoenix, AZ
| | - Leslie R Walker-Harding
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA; Department of Pediatrics, Seattle Children's Hospital, Seattle, WA
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Brummer H, Brophy PD. Pediatric Acute Kidney Injury: Decreasing Incidence and Improving Mortality Disparities Worldwide. Pediatrics 2023; 151:190472. [PMID: 36646625 DOI: 10.1542/peds.2022-059906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/03/2022] [Indexed: 01/18/2023] Open
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Groves AM, Johnston CJ, Beutner GG, Dahlstrom JE, Koina M, O'Reilly MA, Porter G, Brophy PD, Kent AL. Neonatal hypoxic ischemic encephalopathy increases acute kidney injury urinary biomarkers in a rat model. Physiol Rep 2022; 10:e15533. [PMID: 36541220 PMCID: PMC9768655 DOI: 10.14814/phy2.15533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 11/14/2022] [Accepted: 11/15/2022] [Indexed: 12/24/2022] Open
Abstract
Hypoxic ischemic encephalopathy (HIE) is associated with acute kidney injury (AKI) in neonates with birth asphyxia. This study aimed to utilize urinary biomarkers to characterize AKI in an established neonatal rat model of HIE. Day 7 Sprague-Dawley rat pups underwent HIE using the Rice-Vannucci model (unilateral carotid ligation followed by 120 mins of 8% oxygen). Controls included no surgery and sham surgery. Weights and urine for biomarkers (NGAL, osteopontin, KIM-1, albumin) were collected the day prior, daily for 3 days post-intervention, and at sacrifice day 14. Kidneys and brains were processed for histology. HIE pups displayed histological evidence of kidney injury including damage to the proximal tubules, consistent with resolving acute tubular necrosis, and had significantly elevated urinary levels of NGAL and albumin compared to sham or controls 1-day post-insult that elevated for 3 days. KIM-1 significantly increased for 2 days post-HIE. HIE did not significantly alter osteopontin levels. Seven days post-start of experiment, controls were 81.2% above starting weight compared to 52.1% in HIE pups. NGAL and albumin levels inversely correlated with body weight following HIE injury. The AKI produced by the Rice-Vannucci HIE model is detectable by urinary biomarkers, which can be used for future studies of treatments to reduce kidney injury.
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Affiliation(s)
- Angela M. Groves
- Department of PediatricsUniversity of Rochester School of Medicine and DentistryNew YorkRochesterUSA
- Department of Radiation OncologyUniversity of Rochester School of Medicine and DentistryNew YorkRochesterUSA
| | - Carl J. Johnston
- Department of PediatricsUniversity of Rochester School of Medicine and DentistryNew YorkRochesterUSA
| | - Gisela G. Beutner
- Division of CardiologyUniversity of Rochester School of Medicine and DentistryNew YorkRochesterUSA
| | - Jane E. Dahlstrom
- Department of Anatomical Pathology, ACT PathologyCanberra Health ServicesCanberraAustralia
- College of Health and MedicineAustralian National UniversityCanberraAustralia
| | - Mark Koina
- Department of Anatomical Pathology, ACT PathologyCanberra Health ServicesCanberraAustralia
- College of Health and MedicineAustralian National UniversityCanberraAustralia
| | - Michael A. O'Reilly
- Department of PediatricsUniversity of Rochester School of Medicine and DentistryNew YorkRochesterUSA
| | - George Porter
- Division of CardiologyUniversity of Rochester School of Medicine and DentistryNew YorkRochesterUSA
| | - Patrick D. Brophy
- Department of PediatricsUniversity of Rochester School of Medicine and DentistryNew YorkRochesterUSA
- Division of Nephrology, University of Rochester School of Medicine and DentistryGolisano Children's Hospital at University of Rochester Medical CenterNew YorkRochesterUSA
| | - Alison L. Kent
- Department of PediatricsUniversity of Rochester School of Medicine and DentistryNew YorkRochesterUSA
- College of Health and MedicineAustralian National UniversityCanberraAustralia
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Goldstein SL, Akcan-Arikan A, Alobaidi R, Askenazi DJ, Bagshaw SM, Barhight M, Barreto E, Bayrakci B, Bignall ONR, Bjornstad E, Brophy PD, Chanchlani R, Charlton JR, Conroy AL, Deep A, Devarajan P, Dolan K, Fuhrman DY, Gist KM, Gorga SM, Greenberg JH, Hasson D, Ulrich EH, Iyengar A, Jetton JG, Krawczeski C, Meigs L, Menon S, Morgan J, Morgan CJ, Mottes T, Neumayr TM, Ricci Z, Selewski D, Soranno DE, Starr M, Stanski NL, Sutherland SM, Symons J, Tavares MS, Vega MW, Zappitelli M, Ronco C, Mehta RL, Kellum J, Ostermann M, Basu RK. Consensus-Based Recommendations on Priority Activities to Address Acute Kidney Injury in Children: A Modified Delphi Consensus Statement. JAMA Netw Open 2022; 5:e2229442. [PMID: 36178697 PMCID: PMC9756303 DOI: 10.1001/jamanetworkopen.2022.29442] [Citation(s) in RCA: 59] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
IMPORTANCE Increasing evidence indicates that acute kidney injury (AKI) occurs frequently in children and young adults and is associated with poor short-term and long-term outcomes. Guidance is required to focus efforts related to expansion of pediatric AKI knowledge. OBJECTIVE To develop expert-driven pediatric specific recommendations on needed AKI research, education, practice, and advocacy. EVIDENCE REVIEW At the 26th Acute Disease Quality Initiative meeting conducted in November 2021 by 47 multiprofessional international experts in general pediatrics, nephrology, and critical care, the panel focused on 6 areas: (1) epidemiology; (2) diagnostics; (3) fluid overload; (4) kidney support therapies; (5) biology, pharmacology, and nutrition; and (6) education and advocacy. An objective scientific review and distillation of literature through September 2021 was performed of (1) epidemiology, (2) risk assessment and diagnosis, (3) fluid assessment, (4) kidney support and extracorporeal therapies, (5) pathobiology, nutrition, and pharmacology, and (6) education and advocacy. Using an established modified Delphi process based on existing data, workgroups derived consensus statements with recommendations. FINDINGS The meeting developed 12 consensus statements and 29 research recommendations. Principal suggestions were to address gaps of knowledge by including data from varying socioeconomic groups, broadening definition of AKI phenotypes, adjudicating fluid balance by disease severity, integrating biopathology of child growth and development, and partnering with families and communities in AKI advocacy. CONCLUSIONS AND RELEVANCE Existing evidence across observational study supports further efforts to increase knowledge related to AKI in childhood. Significant gaps of knowledge may be addressed by focused efforts.
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Affiliation(s)
- Stuart L Goldstein
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Ayse Akcan-Arikan
- Division of Critical Care Medicine and Nephrology, Texas Children's Hospital, Baylor College of Medicine, Houston
| | - Rashid Alobaidi
- Alberta Health Sciences University, Edmonton, Alberta, Canada
| | | | - Sean M Bagshaw
- Alberta Health Sciences University, Edmonton, Alberta, Canada
| | - Matthew Barhight
- Ann & Robert Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois
| | | | - Benan Bayrakci
- Department of Pediatric Intensive Care Medicine, Life Support Center, Hacettepe University, Ankara, Turkey
| | | | | | - Patrick D Brophy
- Golisano Children's Hospital, Rochester University Medical Center, Rochester, New York
| | | | | | | | - Akash Deep
- King's College London, London, United Kingdom
| | - Prasad Devarajan
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Kristin Dolan
- Mercy Children's Hospital Kansas City, Kansas City, Missouri
| | - Dana Y Fuhrman
- Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Katja M Gist
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Stephen M Gorga
- C.S. Mott Children's Hospital, University of Michigan, Ann Arbor
| | | | - Denise Hasson
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Arpana Iyengar
- St John's Academy of Health Sciences, Bangalore, Karnataka, India
| | | | | | - Leslie Meigs
- Stead Family Children's Hospital, The University of Iowa, Iowa City
| | - Shina Menon
- Seattle Children's Hospital, Seattle, Washington
| | - Jolyn Morgan
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Theresa Mottes
- Ann & Robert Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois
| | - Tara M Neumayr
- Washington University School of Medicine, St Louis, Missouri
| | | | | | | | - Michelle Starr
- Riley Children's Hospital, Indiana University, Bloomington
| | - Natalja L Stanski
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Scott M Sutherland
- Lucille Packard Children's Hospital, Stanford University, Stanford, California
| | | | | | - Molly Wong Vega
- Division of Nephrology, Texas Children's Hospital, Baylor College of Medicine, Houston
| | | | - Claudio Ronco
- Universiti di Padova, San Bartolo Hospital, Vicenza, Italy
| | | | - John Kellum
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Rajit K Basu
- Ann & Robert Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois
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Chmielewski J, Chaudhry PM, Harer MW, Menon S, South AM, Chappell A, Griffin R, Askenazi D, Jetton J, Starr MC, Selewski DT, Sarkar S, Kent A, Fletcher J, Abitbol CL, DeFreitas M, Duara S, Charlton JR, Swanson JR, Guillet R, D’Angio C, Mian A, Rademacher E, Mhanna MJ, Raina R, Kumar D, Jetton JG, Brophy PD, Colaizy TT, Klein JM, Arikan AA, Rhee CJ, Goldstein SL, Nathan AT, Kupferman JC, Bhutada A, Rastogi S, Bonachea E, Ingraham S, Mahan J, Nada A, Cole FS, Davis TK, Dower J, Milner L, Smith A, Fuloria M, Reidy K, Kaskel FJ, Soranno DE, Gien J, Gist KM, Chishti AS, Hanna MH, Hingorani S, Juul S, Wong CS, Joseph C, DuPont T, Ohls R, Staples A, Rohatgi S, Sethi SK, Wazir S, Khokhar S, Perazzo S, Ray PE, Revenis M, Mammen C, Synnes A, Wintermark P, Zappitelli M, Woroniecki R, Sridhar S. Documentation of acute kidney injury at discharge from the neonatal intensive care unit and role of nephrology consultation. J Perinatol 2022; 42:930-936. [PMID: 35676535 PMCID: PMC9280854 DOI: 10.1038/s41372-022-01424-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 04/29/2022] [Accepted: 05/27/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To investigate whether NICU discharge summaries documented neonatal AKI and estimate if nephrology consultation mediated this association. STUDY DESIGN Secondary analysis of AWAKEN multicenter retrospective cohort. EXPOSURES AKI severity and diagnostic criteria. OUTCOME AKI documentation on NICU discharge summaries using multivariable logistic regression to estimate associations and test for causal mediation. RESULTS Among 605 neonates with AKI, 13% had documented AKI. Those with documented AKI were more likely to have severe AKI (70.5% vs. 51%, p < 0.001) and SCr-only AKI (76.9% vs. 50.1%, p = 0.04). Nephrology consultation mediated 78.0% (95% CL 46.5-109.4%) of the total effect of AKI severity and 82.8% (95% CL 70.3-95.3%) of the total effect of AKI diagnostic criteria on documentation. CONCLUSION We report a low prevalence of AKI documentation at NICU discharge. AKI severity and SCr-only AKI increased odds of AKI documentation. Nephrology consultation mediated the associations of AKI severity and diagnostic criteria with documentation.
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Affiliation(s)
- Jennifer Chmielewski
- Department of Pediatrics, Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Paulomi M. Chaudhry
- Department of Pediatrics, Division of Neonatology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Matthew W. Harer
- Department of Pediatrics, Division of Neonatology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Shina Menon
- Division of Nephrology, University of Washington and Seattle Children’s Hospital, Seattle, WA, USA
| | - Andrew M. South
- Department of Pediatrics, Section of Nephrology, Brenner Children’s, Wake Forest School of Medicine, Winston Salem, NC, USA.,Division of Public Health Sciences, Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - Ashley Chappell
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Russell Griffin
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - David Askenazi
- Department of Pediatrics, Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jennifer Jetton
- Division of Nephrology, Dialysis and Transplantation, Stead Family Department of Pediatrics, University of Iowa, Iowa City, IA, USA
| | - Michelle C. Starr
- Department of Pediatrics, Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, USA.,Pediatric and Adolescent Comparative Effectiveness Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA.,Correspondence and requests for materials should be addressed to Michelle C. Starr.
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van der Plas E, Solomon MA, Hopkins L, Koscik T, Schultz J, Brophy PD, Nopoulos PC, Harshman LA. Global and Regional White Matter Fractional Anisotropy in Children with Chronic Kidney Disease. J Pediatr 2022; 242:166-173.e3. [PMID: 34758354 PMCID: PMC8882141 DOI: 10.1016/j.jpeds.2021.11.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 10/29/2021] [Accepted: 11/02/2021] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To investigate the associations between neurocognition and white matter integrity in children with chronic kidney disease (CKD). STUDY DESIGN This cross-sectional study included 17 boys (age 6-16 years) with a diagnosis of mild to moderate (stages 1-3, nondialysis/nontransplant) CKD because of congenital anomalies of the kidney and urinary tract and 20 typically developing community controls. Participants underwent 3T neuroimaging and diffusion-weighted magnetic resonance imaging to assess white matter fractional anisotropy. Multivariable linear regression models were used to evaluate the impact of each group (controls vs CKD) on white matter fractional anisotropy, adjusting for age. Associations between white matter fractional anisotropy and neurocognitive abilities within the CKD group were also evaluated using regression models that were adjusted for age. The false discovery rate was used to account for multiple comparisons; wherein false discovery values <0.10 were considered significant. RESULTS Global white matter fractional anisotropy was reduced in patients with CKD relative to controls (standardized estimate = -0.38, 95% CI -0.69:-0.07), driven by reductions within the body of the corpus callosum (standardized estimate = -0.44, 95% CI -0.75:-0.13), cerebral peduncle (SE = -0.37, 95% CI -0.67:-0.07), cingulum (hippocampus) (standardized estimate = -0.45, 95% CI -0.75:-0.14), and posterior limb of the internal capsule (standardized estimate = -0.46, 95% CI -0.76:-0.15). Medical variables and neurocognitive abilities were not significantly associated with white matter fractional anisotropy. CONCLUSIONS White matter development is vulnerable in children with CKD because of congenital causes, even prior to the need for dialysis or transplantation.
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Affiliation(s)
- Ellen van der Plas
- Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, IA
| | | | - Lauren Hopkins
- Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Timothy Koscik
- Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Jordan Schultz
- Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, IA,University of Iowa College of Pharmacy, Iowa City, IA
| | | | - Peggy C. Nopoulos
- Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, IA
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10
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Weidemann DK, Ashoor IA, Soranno DE, Sheth R, Carter C, Brophy PD. Moving the Needle Toward Fair Compensation in Pediatric Nephrology. Front Pediatr 2022; 10:849826. [PMID: 35359890 PMCID: PMC8960267 DOI: 10.3389/fped.2022.849826] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 01/25/2022] [Indexed: 11/17/2022] Open
Abstract
Remuneration issues are a substantial threat to the long-term stability of the pediatric nephrology workforce. It is uncertain whether the pediatric nephrology workforce will meet the growing needs of children with kidney disease without a substantial overhaul of the current reimbursement policies. In contrast to adult nephrology, the majority of pediatric nephrologists practice in an academic setting affiliated with a university and/or children's hospital. The pediatric nephrology service line is crucial to maintaining the financial health and wellness of a comprehensive children's hospital. However, in the current fee-for-service system, the clinical care for children with kidney disease is neither sufficiently valued, nor appropriately compensated. Current compensation models derived from the relative value unit (RVU) system contribute to the structural biases inherent in the current inequitable payment system. The perceived negative financial compensation is a significant driver of waning trainee interest in the field which is one of the least attractive specialties for students, with a significant proportion of training spots going unfilled each year and relatively stagnant growth rate as compared to the other pediatric subspecialties. This article reviews the current state of financial compensation issues plaguing the pediatric nephrology subspecialty. We further outline strategies for pediatric nephrologists, hospital administrators, and policy-makers to improve the landscape of financial reimbursement to pediatric subspecialists. A physician compensation model is proposed which aligns clinical activity with alternate metrics for current non-RVU producing activities that harmonizes hospital and personal mission statements.
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Affiliation(s)
- Darcy K Weidemann
- Division of Nephrology, Children's Mercy Kansas City, Kansas City, MO, United States.,University of Missouri-Kansas City School of Medicine, Kansas City, MO, United States
| | - I A Ashoor
- Division of Nephrology, LSU Health New Orleans and Children's Hospital, New Orleans, LA, United States
| | - D E Soranno
- Departments of Pediatrics, University of Colorado, Bioengineering, and Medicine, Anschutz Medical Campus, Aurora, CO, United States
| | - R Sheth
- Department of Pediatrics, Loma Linda University Children's Hospital, Loma Linda, CA, United States
| | - C Carter
- Division of Pediatric Nephrology, Rady Children's Hospital, University of California, San Diego, San Diego, CA, United States
| | - P D Brophy
- Department of Pediatrics, University of Rochester School of Medicine, Rochester, NY, United States
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11
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Ashoor I, Weidemann D, Elenberg E, Halbach S, Harshman L, Kula A, Mahan JD, Nada A, Quiroga A, Mahon AR, Smith J, Somers M, Brophy PD. The Pediatric Nephrology Workforce Crisis: A Call to Action. J Pediatr 2021; 239:5-10.e4. [PMID: 33798511 DOI: 10.1016/j.jpeds.2021.03.033] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 03/18/2021] [Indexed: 12/21/2022]
Affiliation(s)
- Isa Ashoor
- Department of Pediatrics, LSU Health School of Medicine, New Orleans, LA
| | - Darcy Weidemann
- Department of Pediatrics, University of Missouri Kansas City School of Medicine, Kansas City, MO.
| | - Ewa Elenberg
- Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Susan Halbach
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
| | - Lyndsay Harshman
- Department of Pediatrics, University of Iowa Stead Family Department of Pediatrics, Iowa City, IA
| | - Alexander Kula
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
| | - John D Mahan
- Department of Pediatrics, The Ohio State University School of Medicine, Columbus, OH
| | - Arwa Nada
- Department of Pediatrics, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN
| | - Alejandro Quiroga
- Department of Pediatrics, Helen DeVos Children's Hospital, Grand Rapids, MI
| | | | - Jodi Smith
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
| | - Michael Somers
- Department of Pediatrics, Harvard Medical School and Boston Children's Hospital, Boston, MA
| | - Patrick D Brophy
- Department of Pediatrics, University of Rochester School of Medicine, Rochester, NY
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12
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Hingorani S, Schmicker RH, Brophy PD, Heagerty PJ, Juul SE, Goldstein SL, Askenazi D. Severe Acute Kidney Injury and Mortality in Extremely Low Gestational Age Neonates. Clin J Am Soc Nephrol 2021; 16:862-869. [PMID: 34117080 PMCID: PMC8216626 DOI: 10.2215/cjn.18841220] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 03/30/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVES AKI is associated with poor short- and long-term outcomes. Questions remain about the frequency and timing of AKI, and whether AKI is a cause of death in extremely low gestational age neonates. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The Recombinant Erythropoietin for Protection of Infant Kidney Disease Study examines the kidney outcomes of extremely low gestational age neonates enrolled in the Preterm Epo Neuroprotection study, a randomized, placebo-controlled trial of recombinant human erythropoietin. We included 900 of 941 patients enrolled in Preterm Epo Neuroprotection. Baseline characteristics were compared by primary exposure (severe AKI versus none/stage 1 AKI) using unadjusted logistic regression models. Cox regression models estimated the relationship between severe AKI and death after adjustment for potential confounders. Time-dependent AKI was modeled as a binary outcome and a categorical variable by stage of AKI. We fit Cox models using time-dependent AKI status lagged by <7 days before death. Landmark analyses examined the relationship of death with development of severe AKI. RESULTS Severe AKI occurred in 168 of 900 (19%, 95% confidence interval, 17% to 20%) neonates, and stage 3 AKI occurred in 60 (7%, 95% confidence interval, 5% to 8%). Stage 3 AKI occurring 7 days before death (hazard ratio, 3.88; 95% confidence interval, 1.26 to 11.96), intraventricular hemorrhage (hazard ratio, 2.01; 95% confidence interval, 1.01 to 3.99) and sepsis (hazard ratio, 2.85; 95% confidence interval, 1.12 to 7.22) were all independently associated with death. Severe AKI occurring 7 days before death (hazard ratio, 2.21; 95% confidence interval, 0.92 to 5.26) was associated with death but not statistically significant. In a landmark analysis, after adjusting for potential confounders, late (after day 14 and before day 28) severe AKI was strongly associated with higher hazard of death (hazard ratio, 4.57; 95% confidence interval, 1.82 to 11.5). CONCLUSIONS Severe AKI occurs frequently in extremely low gestational age neonates. Stage 3 AKI is associated with mortality, and this association is present 7 days before death.
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Affiliation(s)
- Sangeeta Hingorani
- Division of Nephrology, Seattle Children’s Hospital and University of Washington, Seattle, Washington,Department of Biostatistics, University of Washington, Seattle, Washington,Department of Pediatrics, University of Washington, Seattle, Washington
| | | | - Patrick D. Brophy
- Department of Pediatrics, University of Rochester School of Medicine, Rochester, New York
| | | | - Sandra E. Juul
- Department of Pediatrics, University of Washington, Seattle, Washington,Division of Neonatology, Seattle Children’s Hospital and University of Washington, Seattle, Washington
| | - Stuart L. Goldstein
- Division of Nephrology and Hypertension, Cincinnati Children’s Hospital Medical Center and The University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - David Askenazi
- Division of Nephrology, University of Alabama at Birmingham, Children’s of Alabama, Birmingham, Alabama
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13
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Gbadegesin RA, Hernandez LPH, Brophy PD. Case Report: Novel Dietary Supplementation Associated With Kidney Recovery and Reduction in Proteinuria in a Dialysis Dependent Patient Secondary to Steroid Resistant Minimal Change Disease. Front Pediatr 2021; 9:614948. [PMID: 34017803 PMCID: PMC8129002 DOI: 10.3389/fped.2021.614948] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 03/26/2021] [Indexed: 01/13/2023] Open
Abstract
Minimal change disease (MCD) is the most common cause of nephrotic syndrome worldwide. For decades, the foundation of the treatment has been corticosteroids. However, relapse rate is high and up to 40% of patients develop frequent relapsing/steroid dependent course and one third become steroid resistant. This requires treatment with repeated courses of corticosteroids, and second and third line immunomodulators increasing the incidence of drug related adverse effects. More recently, there have been reports of a very small subset of Nephrotic Syndrome (NS) patients who are initially steroid sensitive and later become secondarily steroid resistant. The disease course in this small subset is often protracted leading ultimately to end stage kidney disease requiring dialysis or kidney transplantation. Unfortunately, patients with this disease course do not do well post transplantation because 80% of them will develop disease recurrence that will ultimately lead to graft failure. Few approaches have been tried over many years to reduce the frequency of relapses, and steroid dependence and there is absolutely no therapeutic intervention for patients who develop secondary steroid resistance. Nonetheless, their therapeutic index is low, evidencing the need of a safer complementary treatment. Several hypotheses, including an oxidative stress-mediated mechanism, and immune dysregulation have been proposed to date to explain the underlying mechanism of Minimal Change Disease (MCD) but its specific etiology remains elusive. Here, we report a case of a 54-year-old man with steroid and cyclosporine resistant MCD. The patient rapidly progressed to end stage kidney disease requiring initiation of chronic dialysis. Intradialytic parenteral nutrition (IDPN), albumin infusion along with a proprietary dietary supplement, as part of the supportive therapy, led to kidney function recovery and complete remission of MCD without relapses.
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Affiliation(s)
- Rasheed A Gbadegesin
- Division of Nephrology, Department of Pediatrics, Duke University School of Medicine, Durham, NC, United States
| | | | - Patrick D Brophy
- University of Rochester School of Medicine and Dentistry, Rochester, NY, United States
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14
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Affiliation(s)
- Jeffrey P Yaeger
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, New York.,Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York
| | - Jeffrey Kaczorowski
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Patrick D Brophy
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, New York
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15
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Barach P, Fisher SD, Adams MJ, Burstein GR, Brophy PD, Kuo DZ, Lipshultz SE. Disruption of healthcare: Will the COVID pandemic worsen non-COVID outcomes and disease outbreaks? Prog Pediatr Cardiol 2020; 59:101254. [PMID: 32837144 PMCID: PMC7274978 DOI: 10.1016/j.ppedcard.2020.101254] [Citation(s) in RCA: 91] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Paul Barach
- Department of Pediatrics, Wayne State University School of Medicine, Detroit, MI, United States of America
- Jefferson College of Population Health, Philadelphia, PA, United States of America
- Interdisciplinary Research Institute for Health Law and Science, Sigmund Freud University, Vienna, Austria
| | - Stacy D Fisher
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, United States of America
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, United States of America
| | - M Jacob Adams
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY, United States of America
| | - Gale R Burstein
- Erie County Department of Health, Buffalo, NY, United States of America
- Department of Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, United States of America
| | - Patrick D Brophy
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, NY, United States of America
- Golisano Children's Hospital at the University of Rochester Medical Center, Rochester, NY, United States of America
| | - Dennis Z Kuo
- Department of Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, United States of America
- Oishei Children's Hospital, Buffalo, NY, United States of America
| | - Steven E Lipshultz
- Department of Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, United States of America
- Oishei Children's Hospital, Buffalo, NY, United States of America
- Roswell Park Comprehensive Cancer Center, Buffalo, NY, United States of America
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16
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Brophy PD, Stevenson K, Kaczorowski J, Schriefer J. A Proposed Technique to Enhance Strategic Plan Implementation Using Continuous Quality Improvement Methodologies. J Pediatr 2020; 224:6-9.e2. [PMID: 32826029 DOI: 10.1016/j.jpeds.2020.01.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 01/29/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Patrick D Brophy
- UR Medicine Golisano Children's Hospital, University of Rochester Medical Center, Rochester, NY.
| | - Katy Stevenson
- Office of the CEO and Dean, University of Rochester Medical Center, Rochester, NY
| | - Jeffrey Kaczorowski
- Department of Pediatrics, University of Rochester Medical Center, Rochester, NY
| | - Jan Schriefer
- Department of Pediatrics, University of Rochester Medical Center, Rochester, NY
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17
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Abstract
Background While the use of continuous renal replacement therapies in the management of children with acute renal failure (ARF) has increased, the role of peritoneal dialysis (PD) in the treatment of pediatric ARF has received less attention. Design Retrospective database review of children requiring PD for ARF over a 10-year period. Setting Pediatric intensive care unit at a tertiary-care referral center. Patients Sixty-three children without previously known underlying renal disease who required PD for treatment of ARF. Results Causes of ARF were congestive heart failure (27), hemolytic-uremic syndrome ( 13 ), sepsis ( 10 ), nonrenal organ transplant ( 7 ), malignancy ( 3 ), and other ( 3 ). Mean duration of PD was 11 ± 13 days. Children with ARF were younger (30 ± 48 months vs 88 ± 68 months old, p < 0.0001) and smaller (11.9 ± 15.9 kg vs 28 ± 22 kg, p < 0.0001) than children with known underlying renal disease who began PD during the same time period. Percutaneously placed PD catheters were used in 62% of children with ARF, compared to 4% of children with known renal disease ( p < 0.0001). Hypotension was common in patients with ARF (46%), which correlated with a high frequency of vasopressor use (78%) at the time of initiation of PD. Complications of PD occurred in 25% of patients, the most common being catheter malfunction. Recovery of renal function occurred in 38% of patients; patient survival was 51%. Conclusions Peritoneal dialysis remains an appropriate therapy for pediatric ARF from many causes, even in severely ill children requiring vasopressor support. Such children can be cared for without the use of more expensive and technology-dependent forms of renal replacement therapies.
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Affiliation(s)
- Joseph T. Flynn
- Division of Pediatric Nephrology, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - David B. Kershaw
- Division of Pediatric Nephrology, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - William E. Smoyer
- Division of Pediatric Nephrology, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Patrick D. Brophy
- Division of Pediatric Nephrology, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Kevin D. McBryde
- Division of Pediatric Nephrology, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Timothy E. Bunchman
- Division of Pediatric Nephrology, University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
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18
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Tokhmafshan F, El Andalousi J, Murugapoopathy V, Fillion ML, Campillo S, Capolicchio JP, Jednak R, El Sherbiny M, Turpin S, Schalkwijk J, Matsumoto KI, Brophy PD, Gbadegesin RA, Gupta IR. Children with vesicoureteric reflux have joint hypermobility and occasional tenascin XB sequence variants. Can Urol Assoc J 2019; 14:E128-E136. [PMID: 31702543 DOI: 10.5489/cuaj.6068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION To consider alternative mechanisms that give rise to a refluxing ureterovesical junction (UVJ), we hypothesized that children with a common heritable urinary tract defect, vesicoureteric reflux (VUR), may have a defect in the extracellular matrix composition of the UVJ and other tissues that would be revealed by assessment of the peripheral joints. Hypermobile joints can arise from defects in the extracellular matrix within the joint capsule that affect proteins, including tenascin XB (TNXB). METHODS We performed an observational study of children with familial and non-familial VUR to determine the prevalence of joint hypermobility, renal scarring, and DNA sequence variants in TNXB. RESULTS Most children (27/44) exhibited joint hypermobility using the Beighton scoring system. This included 15/26 girls (57.7%) and 12/18 boys (66.7%), which is a significantly higher prevalence for both sexes when compared to population controls (p<0.005). We found no association between joint hypermobility and renal scarring. Seven of 49 children harbored rare pathogenic sequence variants in TNXB, and two also exhibited joint hypermobility. No sequence variants in TNXB were identified in 25/27 children with VUR and joint hypermobility. Due to the observational design of the study, there was missing data for joint hypermobility scores in six children and for dimercaptosuccinic acid (DMSA) scans in 17 children. CONCLUSIONS We observed a high prevalence of VUR and joint hypermobility in children followed within a tertiary care pediatric urology clinic. While mutations in TNXB have been reported in families with VUR and joint hypermobility, we identified only two children with these phenotypes and pathogenic variants in TNXB. We, therefore, speculate that VUR and joint hypermobility may be due to mutations in other extracellular matrix genes.
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Affiliation(s)
| | - Jasmine El Andalousi
- Research Institute of McGill University Health Centre, Montreal Children's Hospital, Montreal, QC, Canada
| | | | | | - Sarah Campillo
- Department of Pediatrics, Montreal Children's Hospital, McGill University, Montreal, QC, Canada
| | - John-Paul Capolicchio
- Department of Pediatric Surgery, Division of Pediatric Urology, Montreal Children's Hospital and McGill University, Montreal, QC, Canada
| | - Roman Jednak
- Department of Pediatric Surgery, Division of Pediatric Urology, Montreal Children's Hospital and McGill University, Montreal, QC, Canada
| | - Mohamed El Sherbiny
- Department of Pediatric Surgery, Division of Pediatric Urology, Montreal Children's Hospital and McGill University, Montreal, QC, Canada
| | - Sophie Turpin
- Department of Medical Imaging, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montreal, QC, Canada
| | - Joost Schalkwijk
- Department of Dermatology, Nijmegen Centre for Molecular Life Sciences, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Ken-Ichi Matsumoto
- Department of Biosignaling and Radioisotope Experiment, Interdisciplinary Center for Science Research, Organization for Research and Academic Information, Shimane University, Izumo, Shimane, Japan
| | - Patrick D Brophy
- Department of Pediatrics, Golisano Children's Hospital, University of Rochester Medical Center, Rochester, NY, United States
| | - Rasheed A Gbadegesin
- Department of Pediatrics, Division of Nephrology, Duke University Medical Center, Durham, NC, United States
| | - Indra R Gupta
- Department of Human Genetics, McGill University, Montreal, QC, Canada.,Department of Pediatrics, Montreal Children's Hospital, McGill University, Montreal, QC, Canada
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19
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Goldstein SL, Dahale D, Kirkendall ES, Mottes T, Kaplan H, Muething S, Askenazi DJ, Henderson T, Dill L, Somers MJG, Kerr J, Gilarde J, Zaritsky J, Bica V, Brophy PD, Misurac J, Hackbarth R, Steinke J, Mooney J, Ogrin S, Chadha V, Warady B, Ogden R, Hoebing W, Symons J, Yonekawa K, Menon S, Abrams L, Sutherland S, Weng P, Zhang F, Walsh K. A prospective multi-center quality improvement initiative (NINJA) indicates a reduction in nephrotoxic acute kidney injury in hospitalized children. Kidney Int 2019; 97:580-588. [PMID: 31980139 DOI: 10.1016/j.kint.2019.10.015] [Citation(s) in RCA: 92] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 09/26/2019] [Accepted: 10/03/2019] [Indexed: 10/25/2022]
Abstract
Nephrotoxic medication (NTMx) exposure is a common cause of acute kidney injury (AKI) in hospitalized children. The Nephrotoxic Injury Negated by Just-in time Action (NINJA) program decreased NTMx associated AKI (NTMx-AKI) by 62% at one center. To further test the program, we incorporated NINJA across nine centers with the goal of reducing NTMx exposure and, consequently, AKI rates across these centers. NINJA screens all non-critically ill hospitalized patients for high NTMx exposure (over three medications on the same day or an intravenous aminoglycoside over three consecutive days), and then recommends obtaining a daily serum creatinine level in exposed patients for the duration of, and two days after, exposure ending. Additionally, substitution of equally efficacious but less nephrotoxic medications for exposed patients starting the day of exposure was recommended when possible. The main outcome was AKI as defined by the Kidney Disease Improving Global Outcomes (KDIGO) serum creatinine criteria (increase of 50% or 0.3 mg/dl over baseline). The primary outcome measure was AKI episodes per 1000 patient-days. Improvement was defined by statistical process control methodology and confirmed by Autoregressive Integrated Moving Average (ARIMA) modeling. Eight consecutive bi-weekly measure rates in the same direction from the established baseline qualified as special cause change for special process control. We observed a significant and sustained 23.8% decrease in NTMx-AKI rates by statistical process control analysis and by ARIMA modeling; similar to those of the pilot single center. Thus, we have successfully applied the NINJA program to multiple pediatric institutions yielding decreased AKI rates.
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Affiliation(s)
- Stuart L Goldstein
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.
| | - Devesh Dahale
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Eric S Kirkendall
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Theresa Mottes
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Heather Kaplan
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Stephen Muething
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - David J Askenazi
- Division of Nephrology, Children's Hospital of Alabama, Birmingham, Alabama, USA
| | - Traci Henderson
- Division of Nephrology, Children's Hospital of Alabama, Birmingham, Alabama, USA
| | - Lynn Dill
- Division of Nephrology, Children's Hospital of Alabama, Birmingham, Alabama, USA
| | | | - Jessica Kerr
- Division of Nephrology, Children's Hospital, Boston, Massachusetts, USA
| | - Jennifer Gilarde
- Division of Nephrology, Children's Hospital, Boston, Massachusetts, USA
| | - Joshua Zaritsky
- Division of Nephrology, A.I. Dupont Children's Hospital, Wilmington, Delaware, USA
| | - Valerie Bica
- Division of Nephrology, A.I. Dupont Children's Hospital, Wilmington, Delaware, USA
| | - Patrick D Brophy
- Division of Nephrology, Stead Family Children's Hospital, Iowa City, Iowa, USA
| | - Jason Misurac
- Division of Nephrology, Stead Family Children's Hospital, Iowa City, Iowa, USA
| | - Richard Hackbarth
- Division of Nephrology, Helen DeVos Children's Hospital, Grand Rapids, Michigan, USA
| | - Julia Steinke
- Division of Nephrology, Helen DeVos Children's Hospital, Grand Rapids, Michigan, USA
| | - Joann Mooney
- Division of Nephrology, Helen DeVos Children's Hospital, Grand Rapids, Michigan, USA
| | - Sara Ogrin
- Division of Nephrology, Helen DeVos Children's Hospital, Grand Rapids, Michigan, USA
| | - Vimal Chadha
- Division of Nephrology, Children's Mercy Hospital and Clinics, Kansas City, Missouri, USA
| | - Bradley Warady
- Division of Nephrology, Children's Mercy Hospital and Clinics, Kansas City, Missouri, USA
| | - Richard Ogden
- Division of Nephrology, Children's Mercy Hospital and Clinics, Kansas City, Missouri, USA
| | - Wendy Hoebing
- Division of Nephrology, Children's Mercy Hospital and Clinics, Kansas City, Missouri, USA
| | - Jordan Symons
- Division of Nephrology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Karyn Yonekawa
- Division of Nephrology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Shina Menon
- Division of Nephrology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Lisa Abrams
- Division of Nephrology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Scott Sutherland
- Division of Nephrology, Lucille Packard Stanford Children's Hospital, Palo Alto, California, USA
| | - Patricia Weng
- Division of Nephrology, Mattel Children's Hospital, Los Angeles, California, USA
| | - Fang Zhang
- Division of Biostatistics, Harvard Medical School, Boston, Massachusetts, USA; Harvard Pilgrim Healthcare Institute, Boston, Massachusetts, USA
| | - Kathleen Walsh
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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20
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Charlton JR, Boohaker L, Askenazi D, Brophy PD, D'Angio C, Fuloria M, Gien J, Griffin R, Hingorani S, Ingraham S, Mian A, Ohls RK, Rastogi S, Rhee CJ, Revenis M, Sarkar S, Smith A, Starr M, Kent AL. Incidence and Risk Factors of Early Onset Neonatal AKI. Clin J Am Soc Nephrol 2019. [PMID: 34497098 DOI: 10.2215/cjn.03670318.2019.2.test] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Neonatal AKI is associated with poor short- and long-term outcomes. The objective of this study was to describe the risk factors and outcomes of neonatal AKI in the first postnatal week. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The international retrospective observational cohort study, Assessment of Worldwide AKI Epidemiology in Neonates (AWAKEN), included neonates admitted to a neonatal intensive care unit who received at least 48 hours of intravenous fluids. Early AKI was defined by an increase in serum creatinine >0.3 mg/dl or urine output <1 ml/kg per hour on postnatal days 2-7, the neonatal modification of Kidney Disease: Improving Global Outcomes criteria. We assessed risk factors for AKI and associations of AKI with death and duration of hospitalization. RESULTS Twenty-one percent (449 of 2110) experienced early AKI. Early AKI was associated with higher risk of death (adjusted odds ratio, 2.8; 95% confidence interval, 1.7 to 4.7) and longer duration of hospitalization (parameter estimate: 7.3 days 95% confidence interval, 4.7 to 10.0), adjusting for neonatal and maternal factors along with medication exposures. Factors associated with a higher risk of AKI included: outborn delivery; resuscitation with epinephrine; admission diagnosis of hyperbilirubinemia, inborn errors of metabolism, or surgical need; frequent kidney function surveillance; and admission to a children's hospital. Those factors that were associated with a lower risk included multiple gestations, cesarean section, and exposures to antimicrobials, methylxanthines, diuretics, and vasopressors. Risk factors varied by gestational age strata. CONCLUSIONS AKI in the first postnatal week is common and associated with death and longer duration of hospitalization. The AWAKEN study demonstrates a number of specific risk factors that should serve as "red flags" for clinicians at the initiation of the neonatal intensive care unit course. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER Assessment of Worldwide AKI Epidemiology in Neonates (AWAKEN), NCT02443389.
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Affiliation(s)
| | - Louis Boohaker
- University of Alabama at Birmingham, Birmingham, Alabama
| | - David Askenazi
- University of Alabama at Birmingham, Birmingham, Alabama
| | - Patrick D Brophy
- Golisano Children's Hospital, University of Rochester, Rochester, New York
| | - Carl D'Angio
- Golisano Children's Hospital, University of Rochester, Rochester, New York
| | - Mamta Fuloria
- Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
| | - Jason Gien
- Children's Hospital Colorado, University of Colorado, Aurora, Colorado
| | | | - Sangeeta Hingorani
- Seattle Children's Hospital/University of Washington, Seattle, Washington
| | - Susan Ingraham
- Kapi'olani Medical Center for Women and Children, Honolulu, Hawaii
| | - Ayesa Mian
- Golisano Children's Hospital, University of Rochester, Rochester, New York
| | - Robin K Ohls
- University of New Mexico, Albuquerque, New Mexico
| | | | | | - Mary Revenis
- Children's National Medical Center, The George Washington University School of Medicine and The Health Sciences, Washington, DC
| | - Subrata Sarkar
- C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan; and
| | | | - Michelle Starr
- Seattle Children's Hospital/University of Washington, Seattle, Washington
| | - Alison L Kent
- Golisano Children's Hospital, University of Rochester, Rochester, New York
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Charlton JR, Boohaker L, Askenazi D, Brophy PD, Fuloria M, Gien J, Griffin R, Hingorani S, Ingraham S, Mian A, Ohls RK, Rastogi S, Rhee CJ, Revenis M, Sarkar S, Starr M, Kent AL. Late onset neonatal acute kidney injury: results from the AWAKEN Study. Pediatr Res 2019; 85:339-348. [PMID: 30546043 PMCID: PMC6438709 DOI: 10.1038/s41390-018-0255-x] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 11/19/2018] [Accepted: 11/23/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Most studies of neonatal acute kidney injury (AKI) have focused on the first week following birth. Here, we determined the outcomes and risk factors for late AKI (>7d). METHODS The international AWAKEN study examined AKI in neonates admitted to an intensive care unit. Late AKI was defined as occurring >7 days after birth according to the KDIGO criteria. Models were constructed to assess the association between late AKI and death or length of stay. Unadjusted and adjusted odds for late AKI were calculated for each perinatal factor. RESULTS Late AKI occurred in 202/2152 (9%) of enrolled neonates. After adjustment, infants with late AKI had higher odds of death (aOR:2.1, p = 0.02) and longer length of stay (parameter estimate: 21.9, p < 0.001). Risk factors included intubation, oligo- and polyhydramnios, mild-moderate renal anomalies, admission diagnoses of congenital heart disease, necrotizing enterocolitis, surgical need, exposure to diuretics, vasopressors, and NSAIDs, discharge diagnoses of patent ductus arteriosus, necrotizing enterocolitis, sepsis, and urinary tract infection. CONCLUSIONS Late AKI is common, independently associated with poor short-term outcomes and associated with unique risk factors. These should guide the development of protocols to screen for AKI and research to improve prevention strategies to mitigate the consequences of late AKI.
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Affiliation(s)
| | - Louis Boohaker
- University of Alabama at Birmingham, Birmingham, AL, USA
| | - David Askenazi
- University of Alabama at Birmingham, Birmingham, AL, USA
| | - Patrick D Brophy
- Golisano Children's Hospital, University of Rochester School of Medicine, Rochester, NY, USA
| | - Mamta Fuloria
- The Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Jason Gien
- University of Colorado, Children's Hospital Colorado, Aurora, CO, USA
| | | | | | - Susan Ingraham
- Kapi'olani Medical Center for Women and Children, Honolulu, HI, USA
| | - Ayesa Mian
- Golisano Children's Hospital, University of Rochester School of Medicine, Rochester, NY, USA
| | | | | | | | - Mary Revenis
- Children's National Medical Center, The George Washington University School of Medicine and The Health Sciences, Washington, DC, USA
| | - Subrata Sarkar
- C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Michelle Starr
- Seattle Children's Hospital/University of Washington, Seattle, WA, USA
| | - Alison L Kent
- Golisano Children's Hospital, University of Rochester School of Medicine, Rochester, NY, USA
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22
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Charlton JR, Boohaker L, Askenazi D, Brophy PD, D'Angio C, Fuloria M, Gien J, Griffin R, Hingorani S, Ingraham S, Mian A, Ohls RK, Rastogi S, Rhee CJ, Revenis M, Sarkar S, Smith A, Starr M, Kent AL. Incidence and Risk Factors of Early Onset Neonatal AKI. Clin J Am Soc Nephrol 2019; 14:184-195. [PMID: 31738181 PMCID: PMC6390916 DOI: 10.2215/cjn.03670318] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 10/05/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Neonatal AKI is associated with poor short- and long-term outcomes. The objective of this study was to describe the risk factors and outcomes of neonatal AKI in the first postnatal week. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The international retrospective observational cohort study, Assessment of Worldwide AKI Epidemiology in Neonates (AWAKEN), included neonates admitted to a neonatal intensive care unit who received at least 48 hours of intravenous fluids. Early AKI was defined by an increase in serum creatinine >0.3 mg/dl or urine output <1 ml/kg per hour on postnatal days 2-7, the neonatal modification of Kidney Disease: Improving Global Outcomes criteria. We assessed risk factors for AKI and associations of AKI with death and duration of hospitalization. RESULTS Twenty-one percent (449 of 2110) experienced early AKI. Early AKI was associated with higher risk of death (adjusted odds ratio, 2.8; 95% confidence interval, 1.7 to 4.7) and longer duration of hospitalization (parameter estimate: 7.3 days 95% confidence interval, 4.7 to 10.0), adjusting for neonatal and maternal factors along with medication exposures. Factors associated with a higher risk of AKI included: outborn delivery; resuscitation with epinephrine; admission diagnosis of hyperbilirubinemia, inborn errors of metabolism, or surgical need; frequent kidney function surveillance; and admission to a children's hospital. Those factors that were associated with a lower risk included multiple gestations, cesarean section, and exposures to antimicrobials, methylxanthines, diuretics, and vasopressors. Risk factors varied by gestational age strata. CONCLUSIONS AKI in the first postnatal week is common and associated with death and longer duration of hospitalization. The AWAKEN study demonstrates a number of specific risk factors that should serve as "red flags" for clinicians at the initiation of the neonatal intensive care unit course.
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Affiliation(s)
| | - Louis Boohaker
- University of Alabama at Birmingham, Birmingham, Alabama
| | - David Askenazi
- University of Alabama at Birmingham, Birmingham, Alabama
| | - Patrick D Brophy
- Golisano Children's Hospital, University of Rochester, Rochester, New York
| | - Carl D'Angio
- Golisano Children's Hospital, University of Rochester, Rochester, New York
| | - Mamta Fuloria
- Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
| | - Jason Gien
- Children's Hospital Colorado, University of Colorado, Aurora, Colorado
| | | | - Sangeeta Hingorani
- Seattle Children's Hospital/University of Washington, Seattle, Washington
| | - Susan Ingraham
- Kapi'olani Medical Center for Women and Children, Honolulu, Hawaii
| | - Ayesa Mian
- Golisano Children's Hospital, University of Rochester, Rochester, New York
| | - Robin K Ohls
- University of New Mexico, Albuquerque, New Mexico
| | | | | | - Mary Revenis
- Children's National Medical Center, The George Washington University School of Medicine and The Health Sciences, Washington, DC
| | - Subrata Sarkar
- C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan; and
| | | | - Michelle Starr
- Seattle Children's Hospital/University of Washington, Seattle, Washington
| | - Alison L Kent
- Golisano Children's Hospital, University of Rochester, Rochester, New York
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Abstract
Background: Several medical specialty organizations and the American Telemedicine Association have developed specialty-specific guidelines and tips for optimal telemedicine use. Formal introductory education for medical students appears to lag behind these other developments. Introduction: Leaders at the University of Iowa Hospitals and Clinics recognized that students would benefit from an introductory educational program pertinent across all specialties to prepare them for future telemedicine use. The program objective was to introduce a short educational intervention highlighting basic principles to improve knowledge and help students gain confidence with telemedicine technology. Materials and Methods: The program consists of three modules, a video, and a simulation session. The first module presents telemedicine history, current uses, terminology, Medicare-Medicaid rules, and legal issues. The second addresses efficacy, ethical concerns, and best practices. The third reviews steps for success, including environment (sound, lighting, color, and camera placement), communication tips, documentation, and follow-up. The video demonstrates an ideal telemedicine visit. A short quiz follows each module. A 1-h simulation session utilizes case scenarios, telemedicine software, and peripheral equipment. A retrospective pretest and posttest were used to gauge success. Results: One hundred fifty-three second year medical students completed the program during 2017. Ninety-three (60%) completed the questionnaire. Posttest results showed higher (positive) mean scores for all questions addressed in the program regarding basic telemedicine knowledge and confidence issues. Conclusion: This program model was effective in improving basic knowledge and confidence in telemedicine among second-year medical students. We speculate that they are more informed and prepared for future telemedicine rotations and practices.
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Affiliation(s)
- Clayton Walker
- 1The Signal Center for Innovation, University of Iowa Health Ventures (affiliate of University of Iowa Health Care), Iowa City, Iowa.,2University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Harriet Echternacht
- 1The Signal Center for Innovation, University of Iowa Health Ventures (affiliate of University of Iowa Health Care), Iowa City, Iowa.,3Department of Family Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Patrick D Brophy
- 1The Signal Center for Innovation, University of Iowa Health Ventures (affiliate of University of Iowa Health Care), Iowa City, Iowa.,4Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, Iowa
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24
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Goldstein SL, Somers MJG, Brophy PD, Bunchman TE, Baum M, Blowey D, Mahan JD, Flores FX, Fortenberry JD, Chua A, Alexander SR, Hackbarth R, Symons JM. The Prospective Pediatric Continuous Renal Replacement Therapy (ppCRRT) Registry: Design, Development and Data Assessed. Int J Artif Organs 2018; 27:9-14. [PMID: 14984178 DOI: 10.1177/039139880402700104] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Many issues plague the pediatric ARF outcome literature, which include data only from single center sources, a relative lack of prospective study, mixture within studies of renal replacement therapy modality without stratification and inconsistent use of methods to control for patient illness severity in outcome analysis. Since January 2001, the Prospective Pediatric CRRT (ppCRRT) Registry Group has been collecting data from multiple United States pediatric centers to obtain demographic data regarding pediatric patients who receive CRRT, assess the effect of different CRRT prescriptions on circuit function and evaluate the impact of clinical variables on patient outcome. The aim of the current paper is to describe the ppCRRT Registry design, review the decision process and rationale for the options chosen for the ppCRRT format and discuss the analysis plan and future projects envisioned for the ppCRRT Registry.
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25
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Goldstein SL, Hackbarth R, Bunchman TE, Blowey D, Brophy PD. Evaluation of the PRISMA M10® Circuit in Critically Ill Infants with Acute Kidney Injury: A Report from the Prospective Pediatric CRRT Registry Group. Int J Artif Organs 2018; 29:1105-8. [PMID: 17219349 DOI: 10.1177/039139880602901202] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Currently available extracorporeal circuits in the US often require blood priming to prevent hypotension/anemia in smaller pediatric patients. The PRISMA M10 circuit, available in other countries has not received extensive study and has not been cleared for use in the US. We performed an FDA mandated study of the M10 circuit in the US for use in critically ill pediatric patients with acute kidney injury <15 kg in size. FDA guidelines allowed for maximal blood pump flow of 20 ml/min. Fifteen pts (9 M, 6 F, mean size 5.8±2.8 kg, range 2.6–12.5 kg, age 4 d – 13 mo, mean creatinine =1.2±0.7 mg/dL) were studied at 4 ppCRRT centers. Sixty-one filters (range 1–4 circuits per pt) were used (mean circuit life 28.6±22.5 h, range 1 to 74.5 h, 55%>24 h). No blood leaks occurred. All circuits achieved Qb 20 ml/min. Forty-two out of 61 filters clotted and mean circuit life was lower for these filters than those changed for other reasons (23±17 vs. 41±28 h, p<0.005). Circuits using larger access demonstrated significantly longer survival. We conclude that the M10 filter can serve well for CRRT in small pediatric patients. Further study is needed to determine in higher blood flow rates would decrease clotting rates and increase filter life span and ultrafiltration rates.
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26
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Zappitelli M, Ambalavanan N, Askenazi DJ, Moxey-Mims MM, Kimmel PL, Star RA, Abitbol CL, Brophy PD, Hidalgo G, Hanna M, Morgan CM, Raju TN, Ray P, Reyes-Bou Z, Roushdi A, Goldstein SL. Developing a neonatal acute kidney injury research definition: a report from the NIDDK neonatal AKI workshop. Pediatr Res 2017; 82:569-573. [PMID: 28604760 PMCID: PMC9673450 DOI: 10.1038/pr.2017.136] [Citation(s) in RCA: 130] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Accepted: 02/26/2017] [Indexed: 01/03/2023]
Affiliation(s)
- Michael Zappitelli
- Division of Nephrology, Department of Pediatrics, Montreal Children’s Hospital, McGill University Health Centre, Montreal, Québec, Canada
| | - Namasivayam Ambalavanan
- Departments of Pediatrics, Molecular and Cellular Pathology, and Cell, Developmental, and Integrative Biology, University of Alabama at Birmingham, Birmingham, Alabama
| | - David J. Askenazi
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Marva M. Moxey-Mims
- Division of Kidney Urologic and Hematologic Diseases, National Institute of Diabetes, Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Paul L. Kimmel
- Division of Kidney Urologic and Hematologic Diseases, National Institute of Diabetes, Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Robert A. Star
- Division of Kidney Urologic and Hematologic Diseases, National Institute of Diabetes, Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Carolyn L. Abitbol
- Department of Pediatric Nephrology, Holtz Children’s Hospital, University of Miami Miller School of Medicine, Miami, Florida
| | - Patrick D. Brophy
- Department of Pediatrics, University of Iowa Children’s Hospital, Pediatric Nephrology, Dialysis and Transplantation, University of Iowa Healthcare, University of Iowa Health System, Iowa City, Iowa
| | - Guillermo Hidalgo
- Department of Pediatrics, East Carolina University, East Carolina University School of Medicine, Greenville, North Carolina
| | - Mina Hanna
- Department of Pediatrics, University of Kentucky, Lexington, Kentucky
| | | | - Tonse N.K. Raju
- National Institute of Child Health and Human Development, National Institutes of Health, Pregnancy and Perinatology Branch, Bethesda, Maryland
| | - Patricio Ray
- Department of Nephrology, Main Hospital, Children’s National Health System, Washington, DC
| | - Zayhara Reyes-Bou
- Department of Pediatrics, University of Puerto Rico, Medical Sciences Campus, Neonatal Perinatal Medicine Section, San Juan, Puerto Rico
| | - Amani Roushdi
- Department of Pediatrics, Mackenzie Health Hospital, Richmond Hill, Ontario, Canada
| | - Stuart L. Goldstein
- Department of Pediatrics, Cincinnati Children’s Hospital and Medical Center, Cincinnati, USA
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27
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Tokhmafshan F, Brophy PD, Gbadegesin RA, Gupta IR. Vesicoureteral reflux and the extracellular matrix connection. Pediatr Nephrol 2017; 32:565-576. [PMID: 27139901 PMCID: PMC5376290 DOI: 10.1007/s00467-016-3386-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 03/18/2016] [Accepted: 03/21/2016] [Indexed: 12/24/2022]
Abstract
Primary vesicoureteral reflux (VUR) is a common pediatric condition due to a developmental defect in the ureterovesical junction. The prevalence of VUR among individuals with connective tissue disorders, as well as the importance of the ureter and bladder wall musculature for the anti-reflux mechanism, suggest that defects in the extracellular matrix (ECM) within the ureterovesical junction may result in VUR. This review will discuss the function of the smooth muscle and its supporting ECM microenvironment with respect to VUR, and explore the association of VUR with mutations in ECM-related genes.
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Affiliation(s)
| | - Patrick D. Brophy
- Department of Pediatrics, University of Iowa, Carver College of Medicine, Iowa City, IA 52242, USA
| | - Rasheed A. Gbadegesin
- Department of Pediatrics, Division of Nephrology, Duke University Medical Center, Durham, NC 27710, USA,Center for Human Genetics, Duke University Medical Center, Durham, NC 27710, USA
| | - Indra R. Gupta
- Department of Human Genetics, McGill University, Montreal, QC, Canada,Department of Pediatrics, McGill University, Montreal, QC, Canada
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28
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Hanna MH, Dalla Gassa A, Mayer G, Zaza G, Brophy PD, Gesualdo L, Pesce F. The nephrologist of tomorrow: towards a kidney-omic future. Pediatr Nephrol 2017; 32:393-404. [PMID: 26961492 DOI: 10.1007/s00467-016-3357-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Revised: 02/14/2016] [Accepted: 02/15/2016] [Indexed: 12/19/2022]
Abstract
Omics refers to the collective technologies used to explore the roles and relationships of the various types of molecules that make up the phenotype of an organism. Systems biology is a scientific discipline that endeavours to quantify all of the molecular elements of a biological system. Therefore, it reflects the knowledge acquired by omics in a meaningful manner by providing insights into functional pathways and regulatory networks underlying different diseases. The recent advances in biotechnological platforms and statistical tools to analyse such complex data have enabled scientists to connect the experimentally observed correlations to the underlying biochemical and pathological processes. We discuss in this review the current knowledge of different omics technologies in kidney diseases, specifically in the field of pediatric nephrology, including biomarker discovery, defining as yet unrecognized biologic therapeutic targets and linking omics to relevant standard indices and clinical outcomes. We also provide here a unique perspective on the field, taking advantage of the experience gained by the large-scale European research initiative called "Systems Biology towards Novel Chronic Kidney Disease Diagnosis and Treatment" (SysKid). Based on the integrative framework of Systems biology, SysKid demonstrated how omics are powerful yet complex tools to unravel the consequences of diabetes and hypertension on kidney function.
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Affiliation(s)
- Mina H Hanna
- Department of Pediatrics, Kentucky Children's Hospital, University of Kentucky, Lexington, KY, USA
| | | | - Gert Mayer
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Austria
| | - Gianluigi Zaza
- Renal Unit, Department of Medicine, Verona University Hospital, Verona, Italy
| | - Patrick D Brophy
- Pediatric Nephrology, University of Iowa Children's Hospital, Iowa City, IA, USA
| | - Loreto Gesualdo
- Dipartimento Emergenza e Trapianti di Organi (D.E.T.O), University of Bari, Bari, Italy
| | - Francesco Pesce
- Dipartimento Emergenza e Trapianti di Organi (D.E.T.O), University of Bari, Bari, Italy. .,Cardiovascular Genetics and Genomics, National Heart and Lung Institute, Royal Brompton Hospital, Imperial College London, London, UK.
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29
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Brophy PD. Overview on the Challenges and Benefits of Using Telehealth Tools in a Pediatric Population. Adv Chronic Kidney Dis 2017; 24:17-21. [PMID: 28224938 DOI: 10.1053/j.ackd.2016.12.003] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 12/05/2016] [Accepted: 12/05/2016] [Indexed: 11/11/2022]
Abstract
Telehealth in Pediatric Medicine presents many of the same benefits and challenges noted in adult-based medicine. In terms of health care delivery, the promise of improving access and reducing costs using telehealth in Pediatrics, particularly chronic care, is high. The ability to address clinician shortages and provide remote guidance for chronic care pathways from pediatric subspecialists to rural-based referring physicians is a developing model that represents a sustainable and cost-effective strategy to improve pediatric care. The adoption and implementation of consistent telehealth programs require a readjustment of current regulatory rules and a national discussion on reimbursement and compliance standards. Presently, state laws generally define the rules, whereby health systems or practices can use telehealth for patient care and education. Long-term telehealth program development depends on the ongoing value and use case provided by pediatric advocates for this emerging health care delivery model.
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30
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Harshman LA, Ng BG, Freeze HH, Trapane P, Dolezal A, Brophy PD, Brumbaugh JE. Congenital nephrotic syndrome in an infant with ALG1-congenital disorder of glycosylation. Pediatr Int 2016; 58:785-8. [PMID: 27325525 PMCID: PMC4996748 DOI: 10.1111/ped.12988] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Revised: 05/28/2015] [Accepted: 02/29/2016] [Indexed: 01/18/2023]
Abstract
Congenital nephrotic syndrome (NS) in the newborn is most frequently related to mutations in genes specific for structural integrity of the glomerular basement membrane and associated filtration structures within the kidney, resulting in massive leakage of plasma proteins into the urine. Occurrence of congenital NS in a multi-system syndrome is less common. We describe the case of an infant with deteriorating neurological status, seizures, edema, and proteinuria who was found to have a mutation in gene ALG1 and a renal biopsy consistent with congenital NS. Furthermore, we briefly review rare existing case reports documenting congenital NS in patients with mutations in ALG1, and treatment strategies, including novel use of peritoneal dialysis.
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Affiliation(s)
- Lyndsay A Harshman
- Division of Pediatric Nephrology, Stead Family Department of Pediatrics, University of Iowa Children's Hospital, Iowa City, Iowa, USA
| | - Bobby G Ng
- Human Genetics Program Sanford Burnham Prebys Medical Discovery Institute, Sanford Children's Health Research Center, La Jolla, CA, USA
| | - Hudson H Freeze
- Human Genetics Program Sanford Burnham Prebys Medical Discovery Institute, Sanford Children's Health Research Center, La Jolla, CA, USA
| | - Pamela Trapane
- Division of Medical Genetics, Stead Family Department of Pediatrics, University of Iowa Children's Hospital, Iowa City, Iowa, USA
| | - Anna Dolezal
- Department of Pathology, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Patrick D Brophy
- Division of Pediatric Nephrology, Stead Family Department of Pediatrics, University of Iowa Children's Hospital, Iowa City, Iowa, USA
| | - Jane E Brumbaugh
- Division of Neonatology, Stead Family Department of Pediatrics, University of Iowa Children's Hospital, Iowa City, Iowa, USA
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31
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Hanna M, Brophy PD, Giannone PJ, Joshi MS, Bauer JA, RamachandraRao S. Early urinary biomarkers of acute kidney injury in preterm infants. Pediatr Res 2016; 80:218-23. [PMID: 27055185 DOI: 10.1038/pr.2016.70] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 02/02/2016] [Indexed: 01/24/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) in the neonatal intensive care setting is multifactorial and is associated with significant morbidity and mortality. This study evaluates the utility of novel urinary biomarkers to predict the development and/or severity AKI in preterm infants. METHODS We performed a case-control study on a prospective cohort of preterm infants (<32 wk), to compare seven urine biomarkers between 25 infants with AKI and 20 infants without AKI. RESULTS Infants with AKI had significantly higher neutrophil gelatinase-associated lipocalin (NGAL) (median, control (CTRL) vs. AKI; 0.598 vs. 4.24 µg/ml; P < 0.0001). In contrast, urinary epidermal growth factor (EGF) levels were significantly lower in infants who developed AKI compared to controls (median, CTRL vs. AKI; 0.016 vs. 0.006 µg/ml; P < 0.001). The area under the curve (AUC) for NGAL for prediction of stage I AKI on the day prior to AKI diagnosis (day-1) was 0.91, and for the prediction of stage II/III, AKI was 0.92. Similarly, urine EGF was a predictor of renal injury on day -1 (AUC: 0.97 for stage I and 0.86 for stage II/III AKI). CONCLUSION Urinary biomarkers may be useful to predict AKI development prior to changes in serum creatinine (SCr) in preterm infants.
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Affiliation(s)
- Mina Hanna
- Department of Pediatrics, University of Kentucky College of Medicine, Lexington, Kentucky
| | | | - Peter J Giannone
- Department of Pediatrics, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Mandar S Joshi
- Department of Pediatrics, University of Kentucky College of Medicine, Lexington, Kentucky
| | - John A Bauer
- Department of Pediatrics, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Satish RamachandraRao
- O'Brien Center for AKI Research, University of California-San Diego, San Diego, California.,Department of Cell Biology and Molecular Genetics, Devaraj Urs Medical College, Kolar, India
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Selewski DT, Chen A, Shatat IF, Pais P, Greenbaum LA, Geier P, Nelson RD, Kiessling SG, Brophy PD, Quiroga A, Seifert ME, Straatmann CE, Mahan JD, Ferris ME, Troost JP, Gipson DS. Vitamin D in incident nephrotic syndrome: a Midwest Pediatric Nephrology Consortium study. Pediatr Nephrol 2016; 31:465-72. [PMID: 26498119 PMCID: PMC4758900 DOI: 10.1007/s00467-015-3236-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Revised: 09/12/2015] [Accepted: 09/28/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND Cross-sectional studies of children with prevalent nephrotic syndrome (NS) have shown 25-vitamin D (25(OH)D) deficiency rates of 20-100 %. Information on 25(OH)D status in incident patients or following remission is limited. This study aimed to assess 25(OH)D status of incident idiopathic NS children at presentation and longitudinally with short-term observation. METHODS Multicenter longitudinal study of children (2-18 years old) from 14 centers across the Midwest Pediatric Nephrology Consortium with incident idiopathic NS. 25(OH)D levels were assessed at diagnosis and 3 months later. RESULTS Sixty-one children, median age 5 (3, 11) years, completed baseline visit and 51 completed second visit labs. All 61 (100 %) had 25(OH)D < 20 ng/ml at diagnosis. Twenty-seven (53 %) had 25(OH)D < 20 ng/ml at follow-up. Fourteen (28 %) children were steroid resistant. Univariate analysis showed that children prescribed vitamin D supplements were less likely to have 25(OH)D deficiency at follow-up (OR 0.2, 95 % CI 0.04, 0.6). Steroid response, age, and season did not predict 25(OH)D deficiency. Multivariable linear regression modeling showed higher 25(OH)D levels at follow-up by 13.2 ng/ml (SE 4.6, p < 0.01) in children supplemented with vitamin D. CONCLUSIONS In this incident idiopathic NS cohort, all children at diagnosis had 25(OH)D deficiency and the majority continued to have a deficiency at 2-4 months. Supplemental vitamin D decreased the odds of 25(OH)D deficiency at follow-up, supporting a role for supplementation in incident NS.
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Affiliation(s)
- David T. Selewski
- Division of Nephrology, Department of Pediatrics and Communicable Diseases, C.S. Mott Children’s Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Ashton Chen
- Department of Pediatrics, Section of Pediatric Nephrology, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Ibrahim F. Shatat
- Division of Pediatric Nephrology and Hypertension, Sidra Medical and Research Center, Doha, Qatar,Medical University of South Carolina, Charleston, SC, USA
| | - Priya Pais
- Department of Pediatric Nephrology, St. John’s Medical College Hospital, St John’s National Academy of Health Sciences, Bangalore, India
| | | | - Pavel Geier
- Division of Nephrology, Department of Pediatrics, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
| | - Raoul D. Nelson
- Division of Nephrology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | | | - Patrick D. Brophy
- Stead Family Department of Pediatrics, Division of Nephrology, University of Iowa, Iowa City, IA, USA
| | | | - Michael E. Seifert
- Division of Pediatric Nephrology, Department of Pediatrics, Washington University at St. Louis, St. Louis, MO, USA,Department of Pediatrics, Southern Illinois University, Springfield, IL, USA
| | - Caroline E. Straatmann
- Department of Pediatrics, Louisiana State University and Children’s Hospital, New Orleans, LA, USA
| | - John D. Mahan
- Nationwide Children’s Hospital, The Ohio State University, College of Medicine, Columbus, OH, USA
| | - Maria E. Ferris
- Pediatric Nephrology, UNC Kidney Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jonathan P. Troost
- Division of Nephrology, Department of Pediatrics and Communicable Diseases, C.S. Mott Children’s Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Debbie S. Gipson
- Division of Nephrology, Department of Pediatrics and Communicable Diseases, C.S. Mott Children’s Hospital, University of Michigan, Ann Arbor, MI, USA
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Elahi S, Homstad A, Vaidya H, Stout J, Hall G, Wu G, Conlon P, Routh JC, Wiener JS, Ross SS, Nagaraj S, Wigfall D, Foreman J, Adeyemo A, Gupta IR, Brophy PD, Rabinovich CE, Gbadegesin RA. Rare variants in tenascin genes in a cohort of children with primary vesicoureteric reflux. Pediatr Nephrol 2016; 31:247-53. [PMID: 26408188 PMCID: PMC4747108 DOI: 10.1007/s00467-015-3203-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2015] [Revised: 08/10/2015] [Accepted: 08/26/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Primary vesicoureteral reflux (PVUR) is the most common malformation of the kidney and urinary tract, and reflux nephropathy is a major cause of chronic kidney disease in children. Recently, we reported mutations in the tenascin XB gene (TNXB) as a cause of PVUR with joint hypermobility. METHODS To define the role of rare variants in tenascin genes in the etiology of PVUR, we screened a cohort of patients with familial PVUR (FPVUR) and non-familial PVUR (NFPVUR) for rare missense variants inTNXB and the tenascin C gene (TNC) after excluding mutations in ROBO2 and SOX17. RESULTS The screening procedure identified 134 individuals from 112 families with PVUR; two families with mutations in ROBO2 were excluded from further analysis. Rare missense variants in TNXB were found in the remaining 110 families, of which 5/55 (9%) families had FPVUR and 2/55 (4%) had NFPVUR. There were no differences in high-grade reflux or renal parenchymal scarring between patients with and without TNXB variants. All patients with TNXB rare variants who were tested exhibited joint hypermobility. Overall we were able to identify causes of FPVUR in 7/57 (12%) families (9% in TNXB and 3% in ROBO2). CONCLUSIONS In conclusion, the identification of a rare missense variant in TNXB in combination with a positive family history of VUR and joint hypermobility may represent a non-invasive method to diagnose PVUR and warrants further evaluation in other cohorts.
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Affiliation(s)
- Shan Elahi
- Department of Pediatrics, Duke University Medical Center, Durham, NC
| | - Alison Homstad
- Department of Pediatrics, Duke University Medical Center, Durham, NC
,Duke Molecular Physiology Institute, Durham, NC
| | - Himani Vaidya
- Department of Pediatrics, Duke University Medical Center, Durham, NC
,Duke Molecular Physiology Institute, Durham, NC
| | - Jennifer Stout
- Department of Pediatrics, Duke University Medical Center, Durham, NC
| | - Gentzon Hall
- Duke Molecular Physiology Institute, Durham, NC
,Department of Medicine, Duke University Medical Center, Durham, NC
| | - Guanghong Wu
- Duke Molecular Physiology Institute, Durham, NC
,Department of Medicine, Duke University Medical Center, Durham, NC
| | - Peter Conlon
- Department of Pediatrics, Duke University Medical Center, Durham, NC
| | - Jonathan C. Routh
- Department of Pediatrics, Duke University Medical Center, Durham, NC
,Department of Surgery, Division of Urology, Duke University Medical Center, Durham NC
| | - John S. Wiener
- Department of Pediatrics, Duke University Medical Center, Durham, NC
,Department of Surgery, Division of Urology, Duke University Medical Center, Durham NC
| | - Sherry S. Ross
- Department of Surgery, Division of Urology, Duke University Medical Center, Durham NC
,Department of Urology, Pediatric Urology, University of North Carolina Chapel Hill School of Medicine, Chapel Hill, NC
| | - Shashi Nagaraj
- Department of Pediatrics, Duke University Medical Center, Durham, NC
| | - Delbert Wigfall
- Department of Pediatrics, Duke University Medical Center, Durham, NC
| | - John Foreman
- Department of Pediatrics, Duke University Medical Center, Durham, NC
| | - Adebowale Adeyemo
- Center for Research on Genomics and Global Health, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD 20892-5635, USA
| | - Indra R. Gupta
- Department of Pediatrics and Human Genetics, McGill University, Montreal, Quebec, Canada
| | | | | | - Rasheed A. Gbadegesin
- Department of Pediatrics, Duke University Medical Center, Durham, NC
,Duke Molecular Physiology Institute, Durham, NC
,To whom correspondence should be addressed:
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Abstract
Metabolomics, the latest of the "omics" sciences, refers to the systematic study of metabolites and their changes in biological samples due to physiological stimuli and/or genetic modification. Because metabolites represent the downstream expression of genome, transcriptome, and proteome, they can closely reflect the phenotype of an organism at a specific time. As an emerging field in analytical biochemistry, metabolomics has the potential to play a major role in monitoring real-time kidney function and detecting adverse renal events. Additionally, small molecule metabolites can provide mechanistic insights into novel biomarkers of kidney diseases, given the limitations of the current traditional markers. The clinical utility of metabolomics in the field of pediatric nephrology includes biomarker discovery, defining as yet unrecognized biological therapeutic targets, linking of metabolites to relevant standard indices and clinical outcomes, and providing a window of opportunity to investigate the intricacies of environment/genetic interplay in specific disease states.
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Affiliation(s)
- Mina H Hanna
- Department of Pediatrics, University of Kentucky, Lexington, KY, USA
| | - Patrick D Brophy
- Department of Pediatrics, University of Iowa, Iowa City, IA, USA,Corresponding Author: Patrick D. Brophy, MD, Director Pediatric Nephrology, University of Iowa Children’s Hospital, 285 Newton Rd, 1269A CBRB, Iowa City, IA, 52242, Tel: 319-384-3090, Fax: 319-384-3050,
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Brophy PD, Shoham DA, Charlton JR, Carmody JB, Reidy KJ, Harshman L, Segar J, Askenazi D, Askenazi D. Early-life course socioeconomic factors and chronic kidney disease. Adv Chronic Kidney Dis 2015; 22:16-23. [PMID: 25573508 DOI: 10.1053/j.ackd.2014.06.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Revised: 06/12/2014] [Accepted: 06/16/2014] [Indexed: 01/08/2023]
Abstract
Kidney failure or ESRD affects approximately 650,000 Americans, whereas the number with earlier stages of CKD is much higher. Although CKD and ESRD are usually associated with adulthood, it is likely that the initial stages of CKD begin early in life. Many of these pathways are associated with low birth weight and disadvantaged socioeconomic status (SES) in childhood, translating childhood risk into later-life CKD and kidney failure. Social factors are thought to be fundamental causes of disease. Although the relationship between adult SES and CKD has been well established, the role of early childhood SES for CKD risk remains obscure. This review provides a rationale for examining the association between early-life SES and CKD. By collecting data on early-life SES and CKD, the interaction with other periods in the life course could also be studied, allowing for examination of whether SES trajectories (eg, poverty followed by affluence) or cumulative burden (eg, poverty at multiple time points) are more relevant to lifetime CKD risk.
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36
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Gbadegesin RA, Adeyemo A, Webb NJA, Greenbaum LA, Abeyagunawardena A, Thalgahagoda S, Kale A, Gipson D, Srivastava T, Lin JJ, Chand D, Hunley TE, Brophy PD, Bagga A, Sinha A, Rheault MN, Ghali J, Nicholls K, Abraham E, Janjua HS, Omoloja A, Barletta GM, Cai Y, Milford DD, O'Brien C, Awan A, Belostotsky V, Smoyer WE, Homstad A, Hall G, Wu G, Nagaraj S, Wigfall D, Foreman J, Winn MP. HLA-DQA1 and PLCG2 Are Candidate Risk Loci for Childhood-Onset Steroid-Sensitive Nephrotic Syndrome. J Am Soc Nephrol 2014; 26:1701-10. [PMID: 25349203 DOI: 10.1681/asn.2014030247] [Citation(s) in RCA: 91] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Accepted: 09/09/2014] [Indexed: 12/11/2022] Open
Abstract
Steroid-sensitive nephrotic syndrome (SSNS) accounts for >80% of cases of nephrotic syndrome in childhood. However, the etiology and pathogenesis of SSNS remain obscure. Hypothesizing that coding variation may underlie SSNS risk, we conducted an exome array association study of SSNS. We enrolled a discovery set of 363 persons (214 South Asian children with SSNS and 149 controls) and genotyped them using the Illumina HumanExome Beadchip. Four common single nucleotide polymorphisms (SNPs) in HLA-DQA1 and HLA-DQB1 (rs1129740, rs9273349, rs1071630, and rs1140343) were significantly associated with SSNS at or near the Bonferroni-adjusted P value for the number of single variants that were tested (odds ratio, 2.11; 95% confidence interval, 1.56 to 2.86; P=1.68×10(-6) (Fisher exact test). Two of these SNPs-the missense variants C34Y (rs1129740) and F41S (rs1071630) in HLA-DQA1-were replicated in an independent cohort of children of white European ancestry with SSNS (100 cases and ≤589 controls; P=1.42×10(-17)). In the rare variant gene set-based analysis, the best signal was found in PLCG2 (P=7.825×10(-5)). In conclusion, this exome array study identified HLA-DQA1 and PLCG2 missense coding variants as candidate loci for SSNS. The finding of a MHC class II locus underlying SSNS risk suggests a major role for immune response in the pathogenesis of SSNS.
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Affiliation(s)
- Rasheed A Gbadegesin
- Department of Pediatrics, Division of Nephrology and Center for Human Genetics, Duke University Medical Center, Durham, North Carolina
| | - Adebowale Adeyemo
- Center for Research on Genomics and Global Health, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland;
| | - Nicholas J A Webb
- Department of Pediatric Nephrology and NIHR/Wellcome Trust Children's Clinical Research Facility, The University of Manchester, Manchester Academic Health Science Centre, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Larry A Greenbaum
- Division of Pediatric Nephrology, Emory University School of Medicine and Children's Healthcare of Atlanta, Georgia
| | | | | | - Arundhati Kale
- Division of Nephrology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Debbie Gipson
- Department of Pediatrics, Division of Nephrology, University of Michigan, Ann Arbor, Michigan
| | - Tarak Srivastava
- Division of Nephrology, Children's Mercy Hospital, Kansas City, Missouri
| | - Jen-Jar Lin
- Department of Pediatrics, Division of Nephrology, Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina
| | - Deepa Chand
- Department of Pediatrics, Division of Nephrology, Rush University, Chicago, Illinois
| | - Tracy E Hunley
- Department of Pediatrics, Division of Nephrology, Vanderbilt University, Nashville, Tennessee
| | - Patrick D Brophy
- Department of Pediatrics, Division of Nephrology, University of Iowa, Iowa City, Iowa
| | - Arvind Bagga
- Department of Pediatrics, Division of Nephrology, All India Institute of Medical Science, Ansari Nagar, New Delhi, India
| | - Aditi Sinha
- Department of Pediatrics, Division of Nephrology, All India Institute of Medical Science, Ansari Nagar, New Delhi, India
| | - Michelle N Rheault
- Department of Pediatrics, Division of Nephrology, University of Minnesota Amplatz Children's Hospital, Minneapolis, Minnesota
| | - Joanna Ghali
- Department of Nephrology, Royal Melbourne Hospital, Parkville, Australia
| | - Kathy Nicholls
- Department of Nephrology, Royal Melbourne Hospital, Parkville, Australia
| | - Elizabeth Abraham
- Department of Pediatrics, Division of Nephrology, St. Louis University, St. Louis, Missouri
| | - Halima S Janjua
- Pediatric Institute, Center for Pediatric Nephrology, Cleveland Clinic, Cleveland, Ohio
| | - Abiodun Omoloja
- Division of Nephrology, Dayton Children's Hospital, Dayton, Ohio
| | | | - Yi Cai
- Division of Nephrology, Helen Devos Children's Hospital, Grand Rapids, Michigan
| | | | | | - Atif Awan
- Division of Nephrology, The Children's University Hospital, Dublin, Ireland
| | - Vladimir Belostotsky
- Department of Pediatrics, Division of Nephrology, Leeds Teaching Hospital, Leeds, United Kingdom
| | - William E Smoyer
- Center for Clinical and Translational Research, Research Institute at Nationwide Children's Hospital, Columbus, Ohio; and
| | - Alison Homstad
- Department of Pediatrics, Division of Nephrology and Center for Human Genetics, Duke University Medical Center, Durham, North Carolina
| | - Gentzon Hall
- Department of Medicine, Division of Nephrology and Center for Human Genetics, Duke University Medical Center, Durham, North Carolina
| | - Guanghong Wu
- Department of Medicine, Division of Nephrology and Center for Human Genetics, Duke University Medical Center, Durham, North Carolina
| | - Shashi Nagaraj
- Department of Pediatrics, Division of Nephrology and Center for Human Genetics, Duke University Medical Center, Durham, North Carolina
| | - Delbert Wigfall
- Department of Pediatrics, Division of Nephrology and Center for Human Genetics, Duke University Medical Center, Durham, North Carolina
| | - John Foreman
- Department of Pediatrics, Division of Nephrology and Center for Human Genetics, Duke University Medical Center, Durham, North Carolina
| | - Michelle P Winn
- Department of Medicine, Division of Nephrology and Center for Human Genetics, Duke University Medical Center, Durham, North Carolina
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Harshman LA, Muff-Luett M, Neuberger ML, Dagle JM, Shilyansky J, Nester CM, Brophy PD, Jetton JG. Peritoneal dialysis in an extremely low-birth-weight infant with acute kidney injury. Clin Kidney J 2014; 7:582-5. [PMID: 25859376 PMCID: PMC4389134 DOI: 10.1093/ckj/sfu095] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Accepted: 08/15/2014] [Indexed: 11/13/2022] Open
Abstract
Critically ill neonates are at high risk for acute kidney injury (AKI). Renal supportive therapy (RST) can be an important tool for supporting critically ill neonates with AKI, particularly in cases of oliguria and fluid overload. There are few reports of RST for management of oligo-anuric AKI in the extremely low-birth-weight infant weighing <1000 g. We report successful provision of peritoneal dialysis (PD) to an 830-g neonate with oligo-anuric AKI through adaptation of a standard pediatric acute PD catheter.
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Affiliation(s)
- Lyndsay A Harshman
- Stead Family Department of Pediatrics, Division of Pediatric Nephrology , University of Iowa Children's Hospital , Iowa City, IA , USA
| | - Melissa Muff-Luett
- Stead Family Department of Pediatrics, Division of Pediatric Nephrology , University of Iowa Children's Hospital , Iowa City, IA , USA
| | - Mary L Neuberger
- Stead Family Department of Pediatrics, Division of Pediatric Nephrology , University of Iowa Children's Hospital , Iowa City, IA , USA
| | - John M Dagle
- Stead Family Department of Pediatrics, Division of Neonatology , University of Iowa Children's Hospital , Iowa, City , IA , USA
| | - Joel Shilyansky
- Department of Surgery, Division of Pediatric Surgery , University of Iowa Carver College of Medicine , Iowa City , IA , USA
| | - Carla M Nester
- Stead Family Department of Pediatrics, Division of Pediatric Nephrology , University of Iowa Children's Hospital , Iowa City, IA , USA
| | - Patrick D Brophy
- Stead Family Department of Pediatrics, Division of Pediatric Nephrology , University of Iowa Children's Hospital , Iowa City, IA , USA
| | - Jennifer G Jetton
- Stead Family Department of Pediatrics, Division of Pediatric Nephrology , University of Iowa Children's Hospital , Iowa City, IA , USA
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38
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Picconi JL, Muff-Luett MA, Wu D, Bunchman E, Schaefer F, Brophy PD. Kidney-specific expression of GFP by in-utero delivery of pseudotyped adeno-associated virus 9. Mol Ther Methods Clin Dev 2014; 1:14014. [PMID: 26015958 PMCID: PMC4362350 DOI: 10.1038/mtm.2014.14] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Accepted: 03/18/2014] [Indexed: 11/09/2022]
Abstract
Gene therapy targeting of kidneys has been largely unsuccessful. Recently, a recombinant adeno-associated virus (rAAV) vector was used to target adult mouse kidneys. Our hypothesis is that a pseudotyped rAAV 2/9 vector can produce fetal kidney-specific expression of the green fluorescent protein (GFP) gene following maternal tail vein injection of pregnant mice. Pregnant mice were treated with rAAV2/9 vectors with either the ubiquitous cytomegalovirus promoter or the minimal NPHS1 promoter to drive kidney-specific expression of GFP. Kidneys from dams and pups were analyzed for vector DNA, gene expression, and protein. Vector DNA was identified in kidney tissue out to 12 weeks at low but stable levels, with levels higher in dams than that in pups. Robust GFP expression was identified in the kidneys of both dams and pups treated with the cytomegalovirus (CMV)-enhanced green fluorescent protein (eGFP) vector. When treated with the NPHS1-eGFP vector, dams and pups showed expression of GFP only in kidneys, localized to the glomeruli. An 80-fold increase in GFP mRNA expression in dams and a nearly 12-fold increase in pups was found out to 12 weeks of life. Selective targeting of the fetal kidney with a gene therapy vector was achieved by utilizing the pseudotyped rAAV 2/9 vector containing the NPHS1 promoter.
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Affiliation(s)
- Jason L Picconi
- Department of Obstetrics and Gynecology, University of Iowa Hospitals and Clinics , Iowa City, Iowa, USA ; Department of Pediatrics, University of Iowa Children's Hospital , Iowa City, Iowa, USA
| | - Melissa A Muff-Luett
- Department of Pediatrics, University of Iowa Children's Hospital , Iowa City, Iowa, USA
| | - Di Wu
- Department of Pediatrics, University of Iowa Children's Hospital , Iowa City, Iowa, USA
| | - Erik Bunchman
- Department of Pediatrics, University of Iowa Children's Hospital , Iowa City, Iowa, USA
| | - Franz Schaefer
- Division of Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine , Heidelberg, Germany
| | - Patrick D Brophy
- Department of Pediatrics, University of Iowa Children's Hospital , Iowa City, Iowa, USA
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Brophy PD, Alasti F, Darbro BW, Clarke J, Nishimura C, Cobb B, Smith RJ, Manak JR. Genome-wide copy number variation analysis of a Branchio-oto-renal syndrome cohort identifies a recombination hotspot and implicates new candidate genes. Hum Genet 2013; 132:1339-50. [PMID: 23851940 DOI: 10.1007/s00439-013-1338-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Accepted: 07/02/2013] [Indexed: 12/30/2022]
Abstract
Branchio-oto-renal (BOR) syndrome is an autosomal dominant disorder characterized by branchial arch anomalies, hearing loss and renal dysmorphology. Although haploinsufficiency of EYA1 and SIX1 are known to cause BOR, copy number variation analysis has only been performed on a limited number of BOR patients. In this study, we used high-resolution array-based comparative genomic hybridization on 32 BOR probands negative for coding-sequence and splice-site mutations in known BOR-causing genes to identify potential disease-causing genomic rearrangements. Of the >1,000 rare and novel copy number variants we identified, four were heterozygous deletions of EYA1 and several downstream genes that had nearly identical breakpoints associated with retroviral sequence blocks, suggesting that non-allelic homologous recombination seeded by this recombination hotspot is important in the pathogenesis of BOR. A different heterozygous deletion removing the last exon of EYA1 was identified in an additional proband. Thus, in total five probands (14 %) had deletions of all or part of EYA1. Using a novel disease-gene prioritization strategy that includes network analysis of genes associated with other deletions suggests that SHARPIN (Sipl1), FGF3 and the HOXA gene cluster may contribute to the pathogenesis of BOR.
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Affiliation(s)
- Patrick D Brophy
- Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, IA, 52242, USA
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41
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Palevsky PM, Liu KD, Brophy PD, Chawla LS, Parikh CR, Thakar CV, Tolwani AJ, Waikar SS, Weisbord SD. KDOQI US Commentary on the 2012 KDIGO Clinical Practice Guideline for Acute Kidney Injury. Am J Kidney Dis 2013; 61:649-72. [DOI: 10.1053/j.ajkd.2013.02.349] [Citation(s) in RCA: 439] [Impact Index Per Article: 39.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2013] [Accepted: 02/12/2013] [Indexed: 01/22/2023]
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Abstract
BACKGROUND Aminoglycoside exposure is a common cause of acute kidney injury (AKI). Delay in the diagnosis of AKI using conventional biomarkers has been one of the important obstacles in applying early effective interventions. We tested the hypothesis that urinary metabolomics could identify novel early biomarkers for toxic renal injury. METHODS Three-day-old rats were divided into three groups; they received a single daily injection of vehicle (0.9% NaCl solution) or gentamicin at a dose of 10 or 20 mg/kg/d for 7 d. Urine and blood were collected after 3 and 7 d of injections. Urinary metabolites were evaluated using high-performance liquid chromatography and gas chromatography/mass spectrometry. RESULTS A distinct urinary metabolic profile characterized by glucosuria, phosphaturia, and aminoaciduria was identified preceding changes in serum creatinine. At both the gentamicin doses, urinary tryptophan was significantly (P < 0.05) increased (fold change: 1.91 and 2.31 after 3 d; 1.81 and 1.93 after 7 d). Similarly, kynurenic acid, a tryptophan metabolite, showed a significant (P < 0.05) decrease (fold change: 0.26 and 0.24 after 3 d; 0.21 and 0.52 after 7 d), suggesting an interruption of the normal tryptophan metabolism pathway. CONCLUSION We conclude that urinary metabolomic profiling provides a robust approach for identifying early and novel markers of gentamicin-induced AKI.
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Affiliation(s)
- Mina H Hanna
- Department of Pediatrics, University of Iowa, Iowa City, IA
| | | | - Lynn M Teesch
- High Resolution Mass Spectrometry Facility, University of Iowa, Iowa City, IA
| | - David C Kasper
- Department of Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Franz S Schaefer
- Department of Pediatrics, Heidelberg University Hospital, Heidelberg, Germany
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Gbadegesin RA, Brophy PD, Adeyemo A, Hall G, Gupta IR, Hains D, Bartkowiak B, Rabinovich CE, Chandrasekharappa S, Homstad A, Westreich K, Wu G, Liu Y, Holanda D, Clarke J, Lavin P, Selim A, Miller S, Wiener JS, Ross SS, Foreman J, Rotimi C, Winn MP. TNXB mutations can cause vesicoureteral reflux. J Am Soc Nephrol 2013; 24:1313-22. [PMID: 23620400 DOI: 10.1681/asn.2012121148] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Primary vesicoureteral reflux (VUR) is the most common congenital anomaly of the kidney and the urinary tract, and it is a major risk factor for pyelonephritic scarring and CKD in children. Although twin studies support the heritability of VUR, specific genetic causes remain elusive. We performed a sequential genome-wide linkage study and whole-exome sequencing in a family with hereditary VUR. We obtained a significant multipoint parametric logarithm of odds score of 3.3 on chromosome 6p, and whole-exome sequencing identified a deleterious heterozygous mutation (T3257I) in the gene encoding tenascin XB (TNXB in 6p21.3). This mutation segregated with disease in the affected family as well as with a pathogenic G1331R change in another family. Fibroblast cell lines carrying the T3257I mutation exhibited a reduction in both cell motility and phosphorylated focal adhesion kinase expression, suggesting a defect in the focal adhesions that link the cell cytoplasm to the extracellular matrix. Immunohistochemical studies revealed that the human uroepithelial lining of the ureterovesical junction expresses TNXB, suggesting that TNXB may be important for generating tensile forces that close the ureterovesical junction during voiding. Taken together, these results suggest that mutations in TNXB can cause hereditary VUR.
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Askenazi DJ, Goldstein SL, Koralkar R, Fortenberry J, Baum M, Hackbarth R, Blowey D, Bunchman TE, Brophy PD, Symons J, Chua A, Flores F, Somers MJG. Continuous renal replacement therapy for children ≤10 kg: a report from the prospective pediatric continuous renal replacement therapy registry. J Pediatr 2013; 162:587-592.e3. [PMID: 23102589 PMCID: PMC5545826 DOI: 10.1016/j.jpeds.2012.08.044] [Citation(s) in RCA: 82] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2012] [Revised: 08/10/2012] [Accepted: 08/28/2012] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To report circuit characteristics and survival analysis in children weighing ≤10 kg enrolled in the Prospective Pediatric Continuous Renal Replacement Therapy (ppCRRT) Registry. STUDY DESIGN We conducted prospective cohort analysis of the ppCRRT Registry to: (1) evaluate survival differences in children ≤10 kg compared with other children; (2) determine demographic and clinical differences between surviving and non-surviving children ≤10 kg; and (3) describe continuous renal replacement therapy (CRRT) circuit characteristics differences in children ≤5 kg versus 5-10 kg. RESULTS The ppCRRT enrolled 84 children ≤10 kg between January 2001 and August 2005 from 13 US tertiary centers. Children ≤10 kg had lower survival rates than children >10 kg (36/84 [43%] versus 166/260 [64%]; P < .001). In children ≤10 kg, survivors were more likely to have fewer days in intensive care unit prior to CRRT, lower Pediatric Risk of Mortality 2 scores at intensive care unit admission and lower mean airway pressure (P(aw)), higher urine output, and lower percent fluid overload (FO) at CRRT initiation. Adjusted regression analysis revealed that Pediatric Risk of Mortality 2 scores, FO, and decreased urine output were associated with mortality. Compared with circuits from children 5-10 kg at CRRT initiation, circuits from children ≤5 kg more commonly used blood priming for initiation, heparin anticoagulation, and higher blood flows/effluent flows for body weight. CONCLUSION Mortality is more common in children who are ≤10 kg at the time of CRRT initiation. Like other CRRT populations, urine output and FO at CRRT initiation are independently associated with mortality. CRRT prescription differs in small children.
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Affiliation(s)
- David J. Askenazi
- University of Alabama at Birmingham, Children’s of Alabama, Birmingham, AL,Corresponding Author: David J Askenazi, MD., MsPH. University of Alabama at Birmingham, Department of Pediatrics, Division of Nephrology, 1600 7th Ave South, ACC 516, Birmingham, AL 35233.
| | - Stuart L. Goldstein
- Center for Acute Care Nephrology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Rajesh Koralkar
- University of Alabama at Birmingham, Children’s of Alabama, Birmingham, AL
| | - James Fortenberry
- Children’s Healthcare of Atlanta at Egleston, Emory University School of Medicine, Atlanta, GA
| | - Michelle Baum
- Harvard Medical School, Children’s Hospital of Boston, Boston, MA
| | - Richard Hackbarth
- Michigan State University, Helen DeVos Children’s Hospital, Grand Rapids, MI
| | | | - Timothy E. Bunchman
- Children’s Hospital of Richmond at Virginia Commonwealth University, Richmond, VA
| | | | - Jordan Symons
- University of Washington School of Medicine, Seattle Children’s Hospital, Seattle, WA
| | | | - Francisco Flores
- University of South Florida, Morsani College of Medicine, All Children’s Hospital, St. Petersburg, FL
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Harshman LA, Neuberger ML, Brophy PD. Chronic hemodialysis in pediatric patients: technical and practical aspects of use. Minerva Pediatr 2012; 64:159-169. [PMID: 22495190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Chronic kidney disease (CKD) is a continuum of progressive reduction in kidney function lasting for more than three months, due to either structural and/or functional renal abnormalities that may lead to irreversible kidney damage. The term "renal supportive therapy" (RST) generally characterizes the spectrum of dialysis therapies available to support existing renal function in patients with CKD during progression to end-stage renal disease (ESRD) and/or renal transplantation. Chronic RST modalities include conventional hemodialysis, peritoneal dialysis and home hemodialysis therapies. The modality chosen to deliver RST in the pediatric patient is often guided by a variety of factors including institutional resources, local expertise, patient characteristics, treatment goals, and physician preference. Chronic RST in a pediatric population requires the flexible utilization of multiple delivery modalities for effective care across infancy into adulthood and is not typically initiated until GFR declines to between 15-30 mL/min per 1.73 m2, although thresholds for initiation of RST will vary between patients. This review will provide an overview of current approaches to management and technical approaches to pediatric patients requiring chronic hemodialysis.
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Affiliation(s)
- L A Harshman
- Department of Pediatrics, University of Iowa, Carver College of Medicine, Iowa City, IA, USA
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Stewart ZA, Shetty R, Nair R, Reed AI, Brophy PD. Case report: successful treatment of recurrent focal segmental glomerulosclerosis with a novel rituximab regimen. Transplant Proc 2012; 43:3994-6. [PMID: 22172885 DOI: 10.1016/j.transproceed.2011.10.051] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2011] [Accepted: 10/24/2011] [Indexed: 12/12/2022]
Abstract
Focal segmental glomerulosclerosis (FSGS) is the cause of renal failure in more than 10% of pediatric patients undergoing renal transplantation. Recurrent FSGS is a major cause of pediatric allograft failure, with the risk increasing for patients undergoing retransplantation. Standard therapy for recurrent posttransplantation FSGS includes the use of intensive plasmapheresis (PP) in conjunction with cyclophosphamide or high-dose cyclosporine. However, many patients exhibit refractory disease, with rapid progression to allograft loss despite these interventions. Prior studies have reported conflicting data on the efficacy of adding rituximab therapy to the standard treatment regimen for recurrent posttransplantation FSGS. Here we present a successful therapeutic protocol with rapid elimination of PP after initiation of rituximab therapy for an adolescent patient with recurrent FSGS in the immediate postoperative period. The patient has maintained excellent allograft function through 12 months posttransplantation.
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Affiliation(s)
- Z A Stewart
- Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa 52242, USA.
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Brophy PD. Value of biomarkers to assess renal function following pediatric heart transplantation. Pediatr Transplant 2011; 15:543-5. [PMID: 21762330 DOI: 10.1111/j.1399-3046.2011.01551.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Dagle JM, Fisher TJ, Haynes SE, Berends SK, Brophy PD, Morriss FH, Murray JC. Cytochrome P450 (CYP2D6) genotype is associated with elevated systolic blood pressure in preterm infants after discharge from the neonatal intensive care unit. J Pediatr 2011; 159:104-9. [PMID: 21353244 PMCID: PMC3115515 DOI: 10.1016/j.jpeds.2011.01.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2010] [Revised: 10/04/2010] [Accepted: 01/04/2011] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To determine genetic and clinical risk factors associated with elevated systolic blood pressure (ESBP) in preterm infants after discharge from the neonatal intensive care unit (NICU). STUDY DESIGN A convenience cohort of infants born at <32 weeks gestational age was followed after NICU discharge. We retrospectively identified a subgroup of subjects with ESBP (systolic blood pressure [SBP] >90th percentile for term infants). Genetic testing identified alleles associated with ESBP. Multivariate logistic regression analysis was performed for the outcome ESBP, with clinical characteristics and genotype as independent variables. RESULTS Predictors of ESBP were cytochrome P450, family 2, subfamily D, polypeptide 6 (CYP2D6) (rs28360521) CC genotype (OR, 2.92; 95% CI, 1.48-5.79), adjusted for outpatient oxygen therapy (OR, 4.53; 95% CI, 2.23-8.81) and history of urinary tract infection (OR, 4.68; 95% CI, 1.47-14.86). Maximum SBP was modeled by multivariate linear regression analysis: maximum SBP=84.8 mm Hg + 6.8 mm Hg if cytochrome P450, family 2, subfamily D, polypeptide 6 (CYP2D6) CC genotype + 6.8 mm Hg if discharged on supplemental oxygen + 4.4 mm Hg if received inpatient glucocorticoids (P=.0002). CONCLUSIONS ESBP is common in preterm infants with residual lung disease after discharge from the NICU. This study defines clinical factors associated with ESBP, identifies a candidate gene for further testing, and supports the recommendation to monitor blood pressure before age 3 years, as is suggested for term infants.
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Affiliation(s)
- John M Dagle
- Department of Pediatrics, University of Iowa, Iowa City, IA 52242, USA.
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Sutherland SM, Zappitelli M, Alexander SR, Chua AN, Brophy PD, Bunchman TE, Hackbarth R, Somers MJG, Baum M, Symons JM, Flores FX, Benfield M, Askenazi D, Chand D, Fortenberry JD, Mahan JD, McBryde K, Blowey D, Goldstein SL. Fluid overload and mortality in children receiving continuous renal replacement therapy: the prospective pediatric continuous renal replacement therapy registry. Am J Kidney Dis 2009; 55:316-25. [PMID: 20042260 DOI: 10.1053/j.ajkd.2009.10.048] [Citation(s) in RCA: 408] [Impact Index Per Article: 27.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2009] [Accepted: 10/30/2009] [Indexed: 12/15/2022]
Abstract
BACKGROUND Critically ill children with hemodynamic instability and acute kidney injury often develop fluid overload. Continuous renal replacement therapy (CRRT) has emerged as a favored modality in the management of such children. This study investigated the association between fluid overload and mortality in children receiving CRRT. STUDY DESIGN Prospective observational study. SETTING & PARTICIPANTS 297 children from 13 centers across the United States participating in the Prospective Pediatric CRRT Registry. PREDICTOR Fluid overload from intensive care unit (ICU) admission to CRRT initiation, defined as a percentage equal to (fluid in [L] - fluid out [L])/(ICU admit weight [kg]) x 100%. OUTCOME & MEASUREMENTS The primary outcome was survival to pediatric ICU discharge. Data were collected regarding demographics, CRRT parameters, underlying disease process, and severity of illness. RESULTS 153 patients (51.5%) developed < 10% fluid overload, 51 patients (17.2%) developed 10%-20% fluid overload, and 93 patients (31.3%) developed > or = 20% fluid overload. Patients who developed > or = 20% fluid overload at CRRT initiation had significantly higher mortality (61/93; 65.6%) than those who had 10%-20% fluid overload (22/51; 43.1%) and those with < 10% fluid overload (45/153; 29.4%). The association between degree of fluid overload and mortality remained after adjusting for intergroup differences and severity of illness. The adjusted mortality OR was 1.03 (95% CI, 1.01-1.05), suggesting a 3% increase in mortality for each 1% increase in severity of fluid overload. When fluid overload was dichotomized to > or = 20% and < 20%, patients with > or = 20% fluid overload had an adjusted mortality OR of 8.5 (95% CI, 2.8-25.7). LIMITATIONS This was an observational study; interventions were not standardized. The relationship between fluid overload and mortality remains an association without definitive evidence of causality. CONCLUSIONS Critically ill children who develop greater fluid overload before initiation of CRRT experience higher mortality than those with less fluid overload. Further goal-directed research is required to accurately define optimal fluid overload thresholds for initiation of CRRT.
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Affiliation(s)
- Scott M Sutherland
- Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, CA, USA.
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Walters S, Porter C, Brophy PD. Dialysis and pediatric acute kidney injury: choice of renal support modality. Pediatr Nephrol 2009; 24:37-48. [PMID: 18483748 PMCID: PMC2755787 DOI: 10.1007/s00467-008-0826-x] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2007] [Revised: 03/06/2008] [Accepted: 03/07/2008] [Indexed: 02/03/2023]
Abstract
Dialytic intervention for infants and children with acute kidney injury (AKI) can take many forms. Whether patients are treated by intermittent hemodialysis, peritoneal dialysis or continuous renal replacement therapy depends on specific patient characteristics. Modality choice is also determined by a variety of factors, including provider preference, available institutional resources, dialytic goals and the specific advantages or disadvantages of each modality. Our approach to AKI has benefited from the derivation and generally accepted defining criteria put forth by the Acute Dialysis Quality Initiative (ADQI) group. These are known as the risk, injury, failure, loss, and end-stage renal disease (RIFLE) criteria. A modified pediatrics RIFLE (pRIFLE) criteria has recently been validated. Common defining criteria will allow comparative investigation into therapeutic benefits of different dialytic interventions. While this is an extremely important development in our approach to AKI, several fundamental questions remain. Of these, arguably, the most important are "When and what type of dialytic modality should be used in the treatment of pediatric AKI?" This review will provide an overview of the limited data with the aim of providing objective guidelines regarding modality choice for pediatric AKI. Comparisons in terms of cost, availability, safety and target group will be reviewed.
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Affiliation(s)
- Scott Walters
- grid.214458.e0000000086837370CS Mott Children’s Hospital, Department of Pediatrics, Division of Nephrology, University of Michigan, Ann Arbor, MI USA
| | - Craig Porter
- grid.214572.70000000419368294University of Iowa Children’s Hospital, Department of Pediatrics, Division of Nephrology, Hypertension, Dialysis & Transplantation, University of Iowa, Iowa City, IA USA
| | - Patrick D. Brophy
- grid.214572.70000000419368294University of Iowa Children’s Hospital, Department of Pediatrics, Division of Nephrology, Hypertension, Dialysis & Transplantation, University of Iowa, Iowa City, IA USA ,grid.214572.70000000419368294Pediatric Nephrology, University of Iowa, 200 Hawkins Dr., Iowa City, IA 52242 USA
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